Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice.

BACKGROUND: The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers. OBJECTIVES: The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider. RESEARCH DESIGN: This was a retrospective, observational over fiscal years (FY) 2015-2018. SUBJECTS: Veterans receiving primary care services paid for by the VA. MEASURES: Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year. RESULTS: There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care. CONCLUSION: As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.

The Concentration of Opioid Prescriptions by Providers and Among Patients in the Oregon Medicaid Program.

OBJECTIVE: This study examined the distribution of opioid prescribing across providers and patients and the extent to which concentrated distribution predicts opioid misuse. METHODS: Using 2013 Oregon Medicaid claims and the National Provider Identifier Registry, this study identified patients who filled at least one opioid prescription and providers who prescribed opioids for those patients (N=61,477 Medicaid beneficiaries). This study examined the distribution of opioid prescriptions by provider and patient, the extent to which high-volume opioid use was associated with potential opioid misuse, and how this association changed when patients received opioids from providers in the top decile of morphine-equivalent doses (MEQ) prescribed in 2013. This study used four indicators of opioid misuse: doctor and pharmacy shopping for opioid prescriptions, opioid prescription overlap, and opioid and benzodiazepine prescription overlap. RESULTS: Opioid use and prescriptions were heavily concentrated among the top 10% of opioid users and prescribers. Those high-volume opioid users and prescribers accounted for, respectively, 83.2% and 80.8% in MEQ of entire opioids prescribed. Patients' increasing use of opioids (by MEQ) was associated with most measures of opioid misuse. Patients receiving opioids from high-volume prescribers had a higher probability of opioid prescription overlap and opioid and benzodiazepine prescription overlap compared with other patients, but the difference was significant only among patients who received high doses of opioids, and the size of the difference was modest. CONCLUSIONS: Whereas current policies emphasize reducing opioid prescriptions across all patients and providers, study results suggest that focusing policies on high-volume opioid users and prescribers may be more beneficial.