RESUMEN
Reasons for acquiring insurance outside Department of Veterans Affairs (VA) health care coverage among VA enrollees are incompletely understood. To assess Veterans' decision-making and acquisition of non-VA health care insurance in the Affordable Care Act era, we used mailed questionnaires and semistructured interviews in a stratified random sample of VA enrollees <65 years in the Midwest. Of the 3,666 survey participants, 32.1% reported non-VA insurance. Frequently reported reasons included wanting coverage for emergency situations or family members. Those without non-VA insurance cited unaffordability as the main obstacle. Analysis of the semistructured interview data revealed similar findings. In multivariable logistic regression analyses, characteristics associated with non-VA insurance included higher income (>$50,000 vs. <$10,000, odds ratio [OR] = 5.95, 95% confidence interval [CI]: 3.45-10.3, p < .001). As financial barriers exist for acquisition of non-VA insurance and hence community care, it is critically important that VA enrollees' health care needs are met through VA or community providers financed through VA.
Asunto(s)
Cobertura del Seguro , Seguro de Salud , Servicios de Salud para Veteranos/economía , Veteranos , Atención a la Salud , Humanos , Entrevistas como Asunto , Medio Oeste de Estados Unidos , Patient Protection and Affordable Care Act , Encuestas y Cuestionarios , Estados Unidos , United States Department of Veterans AffairsRESUMEN
Importance: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system. Objective: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA. Design, Setting, and Participants: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included. Exposures: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation. Main Outcomes and Measures: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram). Results: A total of 69â¯070 cataract procedures were identified among 50â¯106 patients (66â¯282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53â¯837 [77.9%] White, 10â¯292 [14.9%] Black). Most of the patient population had either overweight (23â¯292 [33.7%] patients) or obesity (27â¯799 [40.2%] patients). Approximately 49% of surgical procedures (33â¯424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2â¯597â¯623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given. Conclusions and Relevance: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.
Asunto(s)
Extracción de Catarata , Pruebas Diagnósticas de Rutina/economía , Atención de Bajo Valor , United States Department of Veterans Affairs/economía , Servicios de Salud para Veteranos/economía , Extracción de Catarata/efectos adversos , Estudios de Cohortes , Electrocardiografía/economía , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Uso Excesivo de los Servicios de Salud/economía , Complicaciones Posoperatorias/prevención & control , Radiografía Torácica/economía , Pruebas de Función Respiratoria/economía , Estados UnidosRESUMEN
PURPOSE: To examine financial toxicity and strain among men in an equal access healthcare system based on social determinants and clinical characteristics. METHODS: Observational study among men receiving prostate cancer care (n = 49) at a Veterans Health Administration (VHA) facility. Financial hardship included overall financial strain and financial toxicity due to healthcare costs. Financial strain was measured with one item asking how much money they have leftover at the end of the month. Financial toxicity was measured with the Comprehensive Score for Financial Toxicity (COST) scale. RESULTS: Comprehensive Score for Financial Toxicity scores among participants indicated moderate levels of financial toxicity (M = 24.4, SD = 9.9). For financial strain, 36% of participants reported that they did not have enough money left over at the end of the month. There were no racial or clinically related differences in financial toxicity, but race and income level had significant associations with financial strain. CONCLUSION: Financial toxicity and strain should be measured among patients in an equal access healthcare system. Findings suggest that social determinants may be important to assess, to identify patients who may be most likely to experience financial hardship in the context of obtaining cancer care and implement efforts to mitigate the burden for those patients.
Asunto(s)
Estrés Financiero/economía , Costos de la Atención en Salud , Gastos en Salud , Accesibilidad a los Servicios de Salud/economía , Neoplasias de la Próstata/economía , Neoplasias de la Próstata/terapia , Determinantes Sociales de la Salud/economía , Servicios de Salud para Veteranos/economía , Adulto , Anciano , Comorbilidad , Estrés Financiero/etnología , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Neoplasias de la Próstata/etnología , Factores Raciales , Medición de Riesgo , Factores de Riesgo , Determinantes Sociales de la Salud/etnología , Estados Unidos/epidemiología , United States Department of Veterans Affairs/economíaAsunto(s)
Servicios de Salud Comunitaria/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Servicios de Salud para Veteranos/legislación & jurisprudencia , Veteranos/legislación & jurisprudencia , Presupuestos , Servicios de Salud Comunitaria/economía , Servicios de Salud Comunitaria/normas , Predicción , Humanos , Registros Médicos , Conciliación de Medicamentos , Satisfacción del Paciente , Atención Dirigida al Paciente/legislación & jurisprudencia , Calidad de la Atención de Salud/legislación & jurisprudencia , Calidad de la Atención de Salud/normas , Factores de Tiempo , Estados Unidos , Veteranos/psicología , Veteranos/estadística & datos numéricos , Servicios de Salud para Veteranos/economía , Servicios de Salud para Veteranos/normasAsunto(s)
Organizaciones de Beneficencia , Infecciones por Coronavirus/epidemiología , Pandemias , Neumonía Viral/epidemiología , Servicios de Salud para Veteranos , Betacoronavirus , COVID-19 , Organizaciones de Beneficencia/economía , Obtención de Fondos , Humanos , SARS-CoV-2 , Reino Unido/epidemiología , Veteranos/psicología , Servicios de Salud para Veteranos/economíaRESUMEN
Background The attitudes of Department of Veterans Affairs ( VA ) cardiovascular clinicians toward the VA 's quality-of-care processes, clinical outcomes measures, and healthcare value are not well understood. Methods and Results Semistructured telephone interviews were conducted with cardiovascular healthcare providers (n=31) at VA hospitals that were previously identified as high or low performers in terms of healthcare value. The interviews focused on VA providers' experiences with measures of processes, outcomes, and value (ie, costs relative to outcomes) of cardiovascular care. Most providers were aware of process-of-care measurements, received regular feedback generated from those data, and used that feedback to change their practices. Fewer respondents reported clinical outcomes measures influencing their practice, and virtually no participants used value data to inform their practice, although several described administrative barriers limiting high-cost care. Providers also expressed general enthusiasm for the VA 's quality measurement/improvement efforts, with relatively few criticisms about the workload or opportunity costs inherent in clinical performance data collection. There were no material differences in the responses of employees of low-performing versus high-performing VA medical centers. Conclusions Regardless of their medical center's healthcare value performance, most VA cardiovascular providers used feedback from process-of-care data to inform their practice. However, clinical outcomes data were used more rarely, and value-of-care data were almost never used. The limited use of outcomes data to inform healthcare practice raises concern that healthcare outcomes may have insufficient influence, whereas the lack of value data influencing cardiovascular care practices may perpetuate inefficiencies in resource use.