Pharmacy use by dual-eligible non-elderly veterans with private healthcare insurance.

BACKGROUND: Utilization of private sector healthcare services among dual enrolled veterans with private healthcare insurance plans (PHIP) has not been well-characterized. Concurrent use of Veterans Health Administration (VHA) and non-VHA pharmacies may increase risk for adverse outcomes. Thus, the objectives of this study were to determine the extent to which dual VHA-PHIP enrollees obtain medications through VHA and non-VHA pharmacies and to characterize medications obtained through non-VHA pharmacies. METHODS: This observational study used merged administrative data from VHA and a predominant regional PHIP to select veterans < 65 years of age, residing in two Midwestern US states, and simultaneously enrolled in both VHA and the PHIP during fiscal years (FY) 2001-2010. Primary outcome measures included counts of prescriptions dispensed from VHA and non-VHA pharmacies, and frequencies of medications dispensed by non-VHA pharmacies based on PHIP claims. RESULTS: Of 5783 veterans who filled ≥ 1 prescription in FY10, 2935 (50.8 %) used non-VHA pharmacies exclusively, 1165 (20.2 %) used VHA pharmacies exclusively and 1683 (29.1 %) were dual users. Health services utilization was higher for dual users compared to exclusive users of either VHA or non-VHA pharmacies across multiple measures, including total prescriptions, outpatient encounters, and inpatient admissions. The most common medications dispensed by non-VHA pharmacies, by proportion of veterans treated, were hydrocodone (20.9 %), amoxicillin (18.5 %), simvastatin (17.5 %), azithromycin (17.4 %), and lisinopril (15.1 %). Antidepressants comprised 3 of 10 most common medications dispensed by VHA, but none of the most common medications dispensed to exclusive non-VHA pharmacy users. CONCLUSIONS: Our findings align with VHA-Medicare dual enrolled veterans where only a minority of veterans used VHA services exclusively. Younger veterans relied disproportionately on VHA for mental health medications.

Dual use of VA and non-VA hospitals by Veterans with multiple hospitalizations.

BACKGROUND: Veterans who are hospitalized in both VA and non-VA hospitals within a short timespan may be at risk for fragmented or conflicting care. To determine the characteristics of these "dual users," we analyzed administrative hospital discharge data for VA-enrolled veterans of any age in seven states, including any VA or non-VA hospitalizations they had in 2004-2007. METHOD: For VA enrollees in Arizona, Iowa, Louisiana, Florida, South Carolina, Pennsylvania, or New York in 2007, we merged 2004-2007 discharge data for all VA hospitalizations and all non-VA hospitalizations listed in state health department or hospital association databases. For patients hospitalized in 2007, we compared those younger or older than 65 years who had one or multiple hospitalizations during the year, split into users of VA hospitals, non-VA hospitals, or both ("dual users"), on demographics, priority for VA care, travel times, principal diagnoses, co-morbidities, lengths of stay, and prior (2004-2006) hospitalizations, using chi-square analysis or ANOVA. Multiply hospitalized patients were compared with multinomial logistic regressions to predict non-VA and dual use. Payers for non-VA hospitalizations also were compared across groups. RESULTS: Of unique inpatients in 2007, 38 % of those 65 or older were hospitalized more than once during the year, as were 32 % of younger patients; 3 and 8 %, respectively, were dual users. Dual users averaged the most index-year (3.7) and prior (1.5) hospitalizations, split evenly between VA and non-VA. They also had higher rates of admission for circulatory diseases, symptoms/signs/ill-defined conditions, and injury and poisoning, and more admissions for multiple diagnostic categories; among younger patients they had the highest rate of mental disorders admissions. Higher income, non-rural residence, greater time to VA care, lower VA priority, prior non-VA hospitalization, no prior VA hospitalization, and several medical categories predicted greater non-VA use. Among younger patients, however, mental disorders predicted more dual use but less exclusively non-VA use. Dual users' non-VA admissions were more likely than others' to be covered by payers other than Medicare or commercial insurance. CONCLUSIONS: Younger dual users require more medical and psychiatric treatment, and rely more on government funding sources. Effective care coordination for these inpatients might improve outcomes while reducing taxpayer burden.

Comparing the characteristics, utilization, efficiency, and outcomes of VA and non-VA inpatient care provided to VA enrollees: a case study in New York.

OBJECTIVE: To compare the characteristics, utilization, and outcomes of Veterans Health Administration (VA) and non-VA inpatient care provided to VA enrollees in New York. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective study examining 110,716 residents of New York State who were enrolled in the VA and had 266,869 inpatient admissions in VA and non-VA hospitals in New York. For each admission, we determined the system of care used (VA or non-VA), patient demographics, and characteristics of the admission, and we calculated VA patients' relative reliance on the VA for inpatient care. For each Major Diagnostic Category (MDC), we examined reliance, patient characteristics, and lengths-of-stay for 2 groups: veterans who were younger than age 65 and those age 65 or older. RESULTS: Fifty-three percent of younger patients' inpatient admissions were in the VA, whereas 32% of older patients' were; however, relative reliance on the VA varied dramatically across the 19 MDCs examined. Across age groups, patients admitted to VA hospitals were younger, less likely to be white, and less likely to live in a rural setting. Those using VA hospitals had lower Charlson scores and received less complex care. For both age groups and across all MDCs, admissions to VA hospitals had substantially higher diagnosis related group-specific observed-to-expected lengths-of-stay. CONCLUSIONS: Younger and older veterans use VA and non-VA hospitals differently for inpatient services. Comprehensive inpatient datasets could inform planners about VA's service market and VA managers about achievable performance benchmarks that are relevant to VA's service population.

When VA patients have non-VA hospitalizations, who pays for what services, and what are the research implications? A New York case study.

OBJECTIVE: To determine, for Veterans Health Administration (VA) enrollees who lived and were hospitalized in New York State between 1998 and 2000, the primary payers for their non-VA admissions, whether the primary payer mix varied by condition treated, and whether the Medicare claims data that VA acquired on its Medicare-enrolled patients captured all or most of their non-VA inpatient care. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective study examining 75,046 residents of New York State who were enrolled in the VA and had 159,843 inpatient admissions in New York hospitals not in the VA system. For each admission, we determined the major diagnostic category, the primary payer for the admission, and whether the patient was Medicare-enrolled. Our analyses separated veterans into those younger than age 65 and those ages 65 or older. RESULTS: The payer mix for younger veterans' non-VA admissions varied considerably by major diagnostic category. Among veterans who also were Medicare enrollees, Medicare did not pay for 10% of the non-VA hospitalizations of older patients or 20% of those for younger patients. CONCLUSIONS: Using only Medicare claims data may significantly underestimate VA patients' reliance on non-VA inpatient care. To better inform planners about VA's service market and diagnosis-specific service utilization patterns across VA and non-VA providers, VA should work with states to develop comprehensive inpatient datasets.

Rare adverse medical events in VA inpatient care: reliability limits to using patient safety indicators as performance measures.

OBJECTIVE: To assess Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) as performance measures using Veterans Administration hospitalization data. DATA SOURCES STUDY SETTING: Nine years (1997-2005) of all Veterans Health Administration (VA) administrative hospital discharge data. STUDY DESIGN: Retrospective analysis using diagnoses and procedures to derive annual rates and standard errors for 13 PSIs. DATA COLLECTION/EXTRACTION METHODS: For either hospitals or hospital networks (Veterans Integrated Service Networks [VISNs]), we calculated the percentages whose PSI rates were consistently high or low across years, as well as 1-year lagged correlations, for each PSI. We related our findings to the average annual number of adverse events that each PSI represents. We also assessed time trends for the entire VA, by VISN, and by hospital. PRINCIPAL FINDINGS: PSI rates are more stable for VISNs than for individual hospitals, but only for those PSIs that reflect the most frequent adverse events. Only the most frequent PSIs yield significant time trends, and only for larger systems. CONCLUSIONS: Because they are so rare, PSIs are not reliable performance measures to compare individual hospitals. The most frequent PSIs are more stable when applied to hospital networks, but needing large patient samples nullifies their potential value to managers seeking to improve quality locally or to patients seeking optimal care.

Reducing avoidable deaths among veterans: directing private-sector surgical care to high-performance hospitals.

OBJECTIVES: We quantified older (65 years and older) Veterans Health Administration (VHA) patients' use of the private sector to obtain 14 surgical procedures and assessed the potential impact of directing that care to high-performance hospitals. METHODS: Using a merged VHA-Medicare inpatient database for 2000 and 2001, we determined where older VHA enrollees obtained 6 cardiovascular surgeries and 8 cancer resections and whether private-sector care was obtained in high- or low-performance hospitals (based on historical performance and determined 2 years in advance of the service year). We then modeled the mortality and travel burden effect of directing private-sector care to high-performance hospitals. RESULTS: Older veterans obtained most of their procedures in the private sector, but that care was equally distributed across high- and low-performance hospitals. Directing private-sector care to high-performance hospitals could have led to the avoidance of 376 to 584 deaths, most through improved cardiovascular care outcomes. Using historical mortality to define performance would produce better outcomes with lower travel time. CONCLUSIONS: Policy that directs older VHA enrollees' private-sector care to high-performance hospitals promises to reduce mortality for VHA's service population and warrants further exploration.

Unintended consequences of regionalizing specialized VA addiction services.

OBJECTIVE: From 1995 to 2000 the Department of Veterans Affairs (VA) dramatically reduced addiction treatment funding and regionalized specialized services to urban centers. By using New York State as an example, this study examined whether regionalization disproportionately affected rural versus urban veterans' use of VA and non-VA inpatient addiction services. METHODS: By using a comprehensive data set of VA and non-VA hospitalizations for 294,748 VA enrollees who were residents of New York State from 1998 to 2000, this study examined admission rates for addiction treatment to VA and non-VA centers to determine how rates differed between rural veterans and urban veterans. RESULTS: Between 1998 and 2000 rural veterans obtained 67% of their inpatient addiction care from the VA, compared with 54% for urban veterans (p<.001). Compared with 1998 levels, the odds ratios of admission to VA facilities for inpatient detoxification fell for both rural and urban veterans to .80 in 1999 and .65 in 2000 (both p<.05). Although odds ratios of non-VA inpatient admission for addiction treatment were stable over time for urban veterans, those for rural veterans fell from 1998 values, falling to .76 in 1999 (not significant) and .62 in 2000 (p<.001) for detoxification and to .66 in 1999 (not significant) and .51 in 2000 for rehabilitation (p<.05). Odds ratios for urban veterans' admission to VA facilities for rehabilitation fell to .51 in terms of 1998 rates in 1999 and .38 in 2000, but rural veterans' odds ratios fell more, to .31 and .16, respectively (p<.001 for all). CONCLUSIONS: In New York regionalization of VA addiction services disproportionately affected rural veterans. Rural veterans experienced concurrent reductions in VA and non-VA inpatient addiction services. The VA and other health care policy makers should consider the potential unintended consequences to rural populations of resource reallocation.

Where do veterans health administration patients obtain heart, liver, and kidney transplants?

We sought to determine whether Veterans Health Administration (VA) enrollees use the VA system or the private sector for solid-organ transplantation and whether VA system use is associated with patients' proximity to a VA transplant center. Using a national VA/Medicare inpatient data set and a comprehensive New York State VA/private-sector inpatient data set for 1998 to 2000, we found that veterans enrolled in the VA system obtained approximately one-half of their liver transplants, but few heart and kidney transplants, in the VA system. Patients were much more likely to use the VA system if they lived in a VA service area that offered relevant transplant services. Our findings suggest that VA transplant centers intended to meet national needs are more likely to serve local residents. Furthermore, our analysis indicates that use of only the VA/Medicare data set may substantially underestimate VA enrollees' reliance on the private sector for health care services.

Differences Among States in Rural Veterans' Use of VHA and Non-VHA Hospitals.

PURPOSE: To understand how vouchers for non-VHA care of VHA-enrolled veterans might affect rural enrollees, we determined how much enrollees use VHA and non-VHA inpatient care, and whether this use varies substantially between rural and urban residents depending on state of residence. METHODS: For veterans listed in the 2007 VHA enrollment file as living in Arizona, Iowa, Louisiana, Tennessee, Florida, South Carolina, Pennsylvania, or New York, we merged 2004-2007 administrative discharge data for all VHA hospitalizations with all non-VHA hospitalizations listed in state health department or hospital association databases. Within states, rural and urban residents (RUCA-defined) were compared on VHA and non-VHA hospitalization rates, overall and for major diagnostic categories. FINDINGS: Non-VHA hospital use was much greater than VHA use, though it also was more variable across states. In states with higher proportions of urban enrollees, use of non-VHA hospitals was lower for small or isolated rural town residents than urban residents; in the more rural states, it was greater. Rural enrollees also used VHA hospitals more than urban enrollees if they lived in the South, but they used VHA hospitals less in other states. Findings were consistent across principal diagnoses, except that in every state, rural veterans were hospitalized less often for mental disorders but more for respiratory diseases. Logistic regressions controlling several covariates consistently showed that very rural enrollees relied on VHA hospitals more than urban enrollees. Vouchers would likely increase non-VHA use more in states with greater rural populations. CONCLUSIONS: Vouchers for non-VHA inpatient care might have greater impact in rural states.

Mental distress among younger veterans before, during, and after the invasion of Iraq.

OBJECTIVE: The purpose of this study was to determine whether patients receiving care from the Department of Veterans Affairs (VA) reported more mental distress as the war in Iraq began or reintensified compared with other respondents to national health surveys. METHODS: Data from the 2000 and 2003 Behavioral Risk Factor Surveillance System (BRFSS) health surveys were analyzed. Unlike in other years, these particular surveys asked respondents whether they were military veterans. As in other years' surveys, these surveys also asked whether respondents used VA medical care. Male respondents were stratified by age and separated into three groups: VA patients, other veterans, and nonveterans. The proportions of respondents who reported five or more recent days of poor mental or physical health were analyzed with chi square tests. RESULTS: Although the number of recent days of poor mental health among nonveterans, other veterans, and older VA patients were stable from 2000 to 2003, younger VA patients in 2003 reported substantially more days of poor mental health in two intervals: during the Iraq war buildup and invasion, and later, when resistance on the ground reintensified. Comparable changes in physical health complaints were not observed. CONCLUSIONS: In times of war, the VA may anticipate more mental health problems among its current patients, particularly younger veterans.

Insured Veterans' Use of VA and Non-VA Health Care in a Rural State.

PURPOSE: To understand how working-age VA-enrolled veterans with commercial insurance use both VA and non-VA outpatient care, and how rural residence affects dual use, for common diagnoses and procedures. METHODS: We analyzed VA and non-VA outpatient treatment records for any months during 2005-2010 that New Hampshire veterans ages <65 were simultaneously enrolled in VA health care and commercial insurance (per NH's mandatory claims database). Controlling for covariates, we used analysis of variance to compare urban and rural VA users, non-VA users, and dual users on travel burden, diagnosis counts, duration in outpatient care, and visit frequencies, and logistic regressions to assess whether rural veterans were as likely to be seen for common conditions and procedures. FINDINGS: More than half of patients were non-VA users and another third were dual users; rural residents were slightly more likely than urban residents to be dual users. For nearly any common diagnosis or procedure, dual users were more likely to have it at some time during treatment than other patients in either VA or non-VA care, but they seldom had it listed in both care systems. Dual users also were seen most often overall, although within either care system they were seen less often than other patients, particularly if they were rural residents living far from care. Rural residence reduced chances of treatment for a wide variety of conditions, though it also was associated with more musculoskeletal and connective tissue diagnoses. It also reduced chances that patients had some diagnostic and treatment procedures but increased the odds of others that may require fewer visits. CONCLUSIONS: Dual users living in rural areas may have less continuity in their health care. Ensuring that rural dual users are identified in primary care should improve access and care coordination.

Veteran Use of Health Care Systems in Rural States: Comparing VA and Non-VA Health Care Use Among Privately Insured Veterans Under Age 65.

OBJECTIVE: To quantify use of VA and non-VA care among working-age veterans with private insurance by linking VA data to private health insurance plan (PHIP) data. METHODS: Demographics and utilization were compared between dual users of VA and non-VA systems versus single-system users for veterans < 65 living in 2 rural Midwestern states concurrently enrolled in VA health care and a PHIP for ≥ 1 complete federal fiscal year from 2000 to 2010. Chi-square and t-tests were used for univariate analyses. VA reliance was computed as the percentage of visits, admissions and prescriptions in VA. Multinomial logistic regression was used to compare characteristics by dual use versus non-VA only or VA only use. RESULTS: Of 16,330 eligible veterans, 54% used both VA and non-VA services, 39% used non-VA only, and 5% used VA only. Compared with single-system use, dual use was associated with older age, priority levels 1-4, service-connected conditions, rural residence, greater years of study eligibility, and enrollment in the PHIP before VA. VA reliance was 33% for outpatient care, 14% for inpatient, and 40% for pharmacy. PHIP data substantially underestimated VA use compared to VA data; 26% who used VA health care had no VA claims in the PHIP dataset. CONCLUSIONS: Over half of working-age veterans enrolled in VA and private insurance used services in both systems. Care coordination efforts across systems should include veterans of all ages, particularly rural veterans more likely to be dual users, and better methods are needed to identify veterans with private insurance and their private providers.

Associations between childbirth and women veterans' VA and non-VA Hospitalizations for major diagnostic categories.

Women Veterans enrolled in Veterans Affairs (VA) health care almost always use non-VA hospitals for childbirth, making it more likely they will use non-VA hospitals for other needs, as well. We compared VA and non-VA hospitalizations obtained by VA enrollees in seven states from 2004 through 2007 to determine whether women aged 18 to 44 were more likely to use VA or non-VA care for diagnoses in certain major categories, and how this use differed between women who did or did not have any pregnancy/childbirth admissions during the 4 years. We found that women were hospitalized much more in non-VA than in VA hospitals, though they were relatively more likely to use VA hospitals for mental illness, digestive system diseases, and neoplasms than other diagnoses. Women who gave birth during the time interval had very few VA admissions for any diagnosis, and compared to other women they were also less likely to be hospitalized for mental health or cancer, but more likely to be hospitalized for infectious and parasitic diseases. VA hospitals were used more by women who were slightly older, sicker, poorer, and living nearer to them. VA-using women tend to have different and greater medical needs than those having children.

Use and Quality of Care at a VA Outreach Clinic in Northern Maine.

OBJECTIVE: To assess use and quality of care at a new 1-day-per-week Veterans Administration Outreach Clinic in remote northern Maine. METHODS: Veterans Administration electronic medical records were abstracted to compare outreach clinic patients seen in its first year to patients seen at the nearest outpatient treatment sites, a small-staff, full-time VA clinic 81 miles away and a community-based outpatient clinic 55 miles away. Chart abstractions (N = 1251) yielded counts of visits, patients newly enrolled in VA care, patients transferring to the outreach clinic, and patients who had and maintained a local non-VA primary care physician, as well as multiple quality of care performance measures using standard VA criteria. RESULTS: The outreach clinic enrolled very few patients new to VA; 96% of its patients were transfers from other sites. For transfers, the average one-way driving burden to reach primary care was reduced by 52.9 miles and 58.1 minutes to reach. Compared to community-based outpatient clinic patients, outreach clinic patients were more likely to have three or more provider visits during the year. Some quality of care measures were lower at the outreach clinic: obesity screenings, referrals to smoking cessation services, diabetes management, and hypertension control. At all three sites, most patients had health insurance coverage and kept a local, non-VA doctor throughout the year. CONCLUSIONS: A part-time outreach clinic improved the convenience of primary care for rural VA outpatients, though quality of care was reduced for some measures related to equipment and staffing limitations. Most patients at any VA site had a local, non-VA medical doctor with whom they remained in care while using VA services.

Health behaviors and utilization among users of complementary and alternative medicine for treatment versus health promotion.

OBJECTIVE: To compare the characteristics, health behaviors, and health services utilization of U.S. adults who use complementary and alternative medicine (CAM) to treat illness to those who use CAM for health promotion. DATA SOURCE: The 2007 National Health Interview Survey (NHIS). STUDY DESIGN: We compared adult (age ≥18 years) NHIS respondents based on whether they used CAM in the prior year to treat an illness (n=973), for health promotion (n=3,281), or for both purposes (n=3,031). We used complex survey design methods to make national estimates and examine respondents' self-reported health status, health behaviors, and conventional health services utilization. PRINCIPAL FINDINGS: Adults who used CAM for health promotion reported significantly better health status and healthier behaviors overall (higher rates of physical activity and lower rates of obesity) than those who used CAM as treatment. While CAM Users in general had higher rates of conventional health services utilization than those who did not use CAM; adults who used CAM as treatment consumed considerably more conventional health services than those who used it for health promotion. CONCLUSION: This study suggests that there are two distinct types of CAM User that must be considered in future health services research and policy decisions.

Defining "rural" for veterans' health care planning.

PURPOSE: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. METHOD: Using residence information for VHA health care enrollees, we compared urban-rural classifications under the VHA, OMB, and RUCA schemes; the distributions of rural enrollees across VHA health care networks (Veterans Integrated Service Networks [VISNs]); and how each scheme indicates whether VHA standards for travel time to care are met for the most rural veterans. RESULTS: VHA's Highly Rural and Urban categories are much smaller than the most rural or most urban categories in the other schemes, while its Rural category is much larger than their intermediate categories. Most Highly Rural veterans live in VISNs serving the Rocky Mountains and Alaska. Veterans defined as the most rural by RUCA or OMB are distributed more evenly across most VISNs. Nearly all urban enrollees live within VHA standards for travel time to access VHA care; so do most enrollees defined by RUCA or OMB as the most rural. Only half of Highly Rural enrollees, however, live within an hour of primary care, and 70% must travel more than 2 hours to acute care or 4 hours to tertiary care. CONCLUSIONS: VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans' health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.

A longitudinal analysis of rural and urban veterans' health-related quality of life.

CONTEXT: Cross-sectional studies have identified rural-urban disparities in veterans' health-related quality-of-life (HRQOL) scores. PURPOSE: To determine whether longitudinal analyses confirmed that these disparities in veterans' HRQOL scores persisted. METHODS: We obtained data from the SF-12 portion of the veterans health administration's (VA's) Survey of Healthcare Experiences of Patients (SHEP) collected between 2002 and 2006. During that time, the SHEP was randomly administered to approximately 250,000 veterans annually who had used VA outpatient services. We evaluated 163,709 responses from veterans who had completed 2 or more surveys during the years studied. Respondents were classified into rural-urban groups using ZIP Code-based rural-urban commuting area designations. We estimated linear regression models using generalized estimating equations to determine whether rural and urban veterans' HRQOL scores were changing at different rates over the time period examined. FINDINGS: After adjustment for sociodemographic differences, we found that urban veterans had substantially better physical HRQOL scores than their rural counterparts and that these differences persisted over the study period. While urban veterans had worse mental HRQOL scores than rural veterans, those differences diminished over the time period studied. CONCLUSIONS: Rural-urban disparities in HRQOL scores persist when tracking veterans longitudinally. Reduced access among rural veterans to care may contribute to these disparities. Because rural soldiers are overrepresented in current conflicts, the VA should consider new models of care delivery to improve access to care for rural veterans.

Health care expenditures for urban and rural veterans in Veterans Health Administration care.

OBJECTIVE: To compare Veterans Health Administration (VA) patients, non-VA-using veterans, and nonveterans, separated by urban/rural residence and age group, on their use of major categories of medical care and payment sources. DATA SOURCE: Expenditures for health care-using men in Medical Expenditure Panel Surveys from 1996 through 2004. STUDY DESIGN: Retrospective, cross-sectional analysis. DATA COLLECTION/EXTRACTION METHODS: Controlling for demographics, health status, and insurance, we compared groups on population-weighted expenditures for inpatient, hospital-based outpatient, office-based, pharmacy, and other care, by major payers (self/family, private insurance, Medicare, other sources, and VA). RESULTS: VA users received most of their health care outside of the VA system, paid through private insurance or Medicare; self-payments were substantial. VA users under 65 reported worse health if they were rural residents but also lower expenditures overall and less care through private insurance. CONCLUSIONS: VA health care users get most of their medical care from non-VA providers. Working-age VA users have less insurance coverage and rely more on VA care if they live in rural areas.