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RESEARCH FINDINGS #39:
Ambulatory Care Use and Expenditures among Non-Elderly Veterans, 2011–2015
Highlights
- The average annual population of non-elderly Veterans was 9.7 million during the 2011–2015 period. Among non-elderly Veterans, 77.7 percent had at least one ambulatory care visit, 11.1 percent had only VA visits, 52.4 percent had only non-VA visits, and 14.3 percent had both VA and non-VA visits.
- Veterans with only non-VA ambulatory care visits and Veterans with both types of visits were more likely to be women than Veterans whose ambulatory visits were only within the VA system (13.0 and 15.3 percent versus 7.2 percent, respectively).
- On average, the VA paid for 25.5 percent, 91.0 percent, and 41.0 percent of expenditures for ambulatory visits for all Veterans, those with only VA visits, and those with visits inside as well as outside the VA system, respectively.
- Average out-of-pocket payments were significantly higher for Veterans with only non-VA ambulatory care visits ($268) and for Veterans with both types of visits ($316) compared to Veterans with only ambulatory visits in the VA health care system ($14).
- Veterans with both VA and non-VA ambulatory care visits had significantly higher average total ambulatory expenditures ($5,697) than Veterans with only VA visits ($2,279) or only non-VA visits ($2,179).
Introduction
Examining Veterans' current use of health care both inside and outside of the Department of Veterans Affairs' (VA) health care system provides helpful information for predicting Veterans' future demand for VA health care. Predicting such demand is important for ensuring that adequate resources and capabilities will be available to meet the unique and changing health care needs of Veterans. This report uses pooled data from 2011 to 2015 from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) to examine ambulatory care use and expenditures among non-elderly Veterans ages 18-64 in the U.S. noninstitutionalized population. Since the MEPS-HC contains information on health care use inside and outside of the VA health system, it is a unique data source for analyzing Veterans' total health care use.Veterans' eligibility for VA health care use is based on many factors, including active duty military service, type of military discharge, service-connected disabilities, medical conditions incurred while in the service, location and dates of military service, deployments on which they served, and miscellaneous other criteria. Veterans' reliance on VA health care versus outside care is also based on multiple factors, such as whether Veterans are eligible to receive free VA care, whether they have private or public health insurance coverage, and the generosity of their insurance coverage relative to the cost of receiving VA care.
In this report, Veterans' use of ambulatory care is categorized as follows: 1) use of only VA ambulatory care; 2) use of only non-VA ambulatory care; and 3) use of both types of ambulatory care. Veterans whose ambulatory care visits all had at least some portion of their associated medical expenditures paid for by the VA are classified as using "only VA care," while Veterans for whom no ambulatory care visits had any portion of expenditures paid for by the VA are classified as using "only non-VA care." Veterans with some ambulatory care visits having at least some medical expenditures paid for by the VA and some for which none of the associated expenditures were paid for by the VA are classified as having a "mix of VA and non-VA care."
This report contains estimates of the percentage of Veterans in each of these three use categories, and descriptive statistics on the sociodemographic characteristics of Veterans in each group. With respect to the use of ambulatory care, the report presents person-level estimates of the mean number of ambulatory care visits as well as estimates of total expenditures and sources of payment for these visits, both overall and separately by use category. The expenditure estimates represent average annual expenditure estimates for the 2011–2015 period, with all dollar amounts adjusted to 2015 dollars using the all urban Consumer Price Index. Only differences that are statistically significant at the 0.05 level or better are described in the text unless otherwise noted.
Findings
Ambulatory care use among VeteransThe average annual population of non-elderly Veterans was 9.7 million during the period from 2011 to 2015 (Table 1). Among non-elderly Veterans, 77.7 percent had at least one ambulatory care visit, 11.1 percent had only VA ambulatory care visits, 52.4 percent had only non-VA ambulatory care visits, and 14.3 percent had both VA and non-VA ambulatory care visits.
Sociodemographic characteristics of Veterans by use category
Age
Compared to Veterans with only VA ambulatory care visits, Veterans with only non-VA visits and those with both types of visits were less likely to be ages 18-39 (17.7 and 15.3 percent versus 25.1 percent) and more likely to be ages 40-54 (41.5 and 36.7 percent versus 29.6 percent, p<0.10 for the comparison with a mix of visits) than those with only VA visits (Table 2). Compared to Veterans with only VA visits, Veterans with no ambulatory care use were more likely to be ages 40-54 (42.2 percent versus 29.6 percent) and less likely to be ages 55-64 (28.2 percent versus 45.4 percent).
Sex
Veterans with only non-VA ambulatory care visits and those with both types of visits were more likely to be women than Veterans with ambulatory care visits only within the VA system (13.0 and 15.3 percent versus 7.2 percent, respectively).
Race/ethnicity
Veterans with only non-VA ambulatory care visits and those with both types of visits were less likely than those with only VA visits to be non-Hispanic black (12.8 and 16.2 percent versus 22.6 percent, respectively). Those with only non-VA visits were more likely to be white and other racial/ethnic groups than those with only VA visits (81.5 percent versus 69.5 percent).
Perceived health status
Compared to Veterans with only VA ambulatory care visits, Veterans with only non-VA visits were more likely to report having very good (37.2 percent versus 27.8 percent) or excellent health (20.9 percent versus 11.2 percent) and were less likely to report having fair or poor health (12.6 percent versus 26.1 percent). Perceived health status did not vary significantly between Veterans with only VA ambulatory care visits and those with both types of visits. Veterans with no ambulatory care visits were more likely to report having excellent health than those with only VA visits (31.3 percent versus 11.2 percent) and they were less likely to report having fair or poor health (6.0 percent versus 26.1 percent).
Insurance status
Veterans with only non-VA ambulatory care visits and with both types of visits were more likely to have private insurance than those with only VA visits (89.0 and 75.0 percent versus 63.3 percent, respectively) and they were less likely to be uninsured (6.0 and 9.9 percent versus 24.2 percent, respectively). Veterans with no ambulatory care visits were more likely to have private insurance than those with only VA visits (71.5 percent versus 63.3 percent) and they were less likely to have public insurance (4.8 percent versus 12.5 percent).
Poverty status
Veterans with only non-VA ambulatory care visits and those with both types of visits were more likely to have higher incomes than those with only VA visits. In the 2011–2015 period, 58.1 percent of Veterans with only non-VA visits and 46.5 percent of Veterans with both types of visits had high income versus 22.0 percent of Veterans with only VA visits. In the same time period, 42.5 percent of Veterans with only VA visits had poor/near poor or low income compared to 13.7 percent of Veterans with only non-VA visits, and 26.8 percent of Veterans with both types of visits.
Urbanicity
Veterans with only non-VA ambulatory care visits were more likely to live in Metropolitan Statistical Areas than those with only VA visits (85.5 percent versus 78.0 percent). Urbanicity did not vary significantly between Veterans with only VA ambulatory care visits and Veterans with both types of visits.
Average number of VA and non-VA ambulatory care visits
Veterans with only VA ambulatory care visits and Veterans with only non-VA use both had approximately seven ambulatory care visits per year (Table 3). However, the average number of ambulatory care visits among Veterans with a mix of VA and non-VA use was more than twice as large (14.8 visits). Veterans in this category had fewer VA visits than those with only VA use (5.5 visits versus 6.9 visits) but they had an additional 9.3 visits outside the VA system. Veterans with a mix of visits also had higher non-VA use than those whose visits were all outside the VA system (9.3 visits versus 7.0 visits).
Distribution of ambulatory expenditures by sources of payment
On average, the VA paid for 25.5 percent of total ambulatory care expenditures among Veterans with any ambulatory care visits (Table 4). This figure rose to 91.0 percent for Veterans with only VA ambulatory care visits. For Veterans with both VA and non-VA ambulatory care visits, payments by the VA accounted for 41.0 percent of their total ambulatory care expenditures.
Veterans with only non-VA ambulatory care visits and those with both types of visits paid a higher share of the associated expenditures out of pocket than those with only VA ambulatory care visits (12.3 and 5.5 percent versus 0.6 percent, respectively). Private insurance accounted for a larger share of total ambulatory care expenditures for Veterans with only non-VA ambulatory care use and both types of visits than those with only visits within the VA system (73.4 and 35.7 percent versus 6.8 percent, respectively). Public insurance also accounted for a larger share of total ambulatory care expenditures for Veterans with only non-VA ambulatory care visits and with both types of visits than for those with only visits within the VA system (9.0 and 10.6 percent versus 1.3 percent, respectively).
Average ambulatory expenditures by source of payment
Veterans with both VA and non-VA ambulatory care visits had significantly higher average ambulatory expenditures than Veterans with only VA and with only non-VA visits ($5,697 versus $2,279 and $2,179, respectively) (Table 5). Average payments by the VA were similar for Veterans with only VA visits and those with both types of visits ($2,073 and $2,338, respectively).
Average out-of-pocket payments were significantly higher for Veterans with only non-VA ambulatory care visits ($268) and those with both types of visits ($316) than for Veterans with only VA visits ($14). Average payments by private insurance were significantly higher for Veterans with only non-VA ambulatory care visits ($1,600) and Veterans with both types of visits ($2,032) than for Veterans with visits only within the VA system ($154). Average payments by public insurance were also significantly higher for Veterans with only non-VA ambulatory care visits ($195) and those with both types of visits ($602) than for Veterans with only visits within the VA system ($29).
Data Source
The estimates in this Research Findings are based on data from the MEPS 2011–2015 Full Year Consolidated Data Files (HC-147, HC-155, HC-163, HC-171, HC-181), MEPS 2011–2015 Office-Based Medical Provider Visits Files (HC-144G, HC-152G, HC-160G, HC-168G, HC-178G), and MEPS 2011–2015 Outpatient Visits Files (HC-144F, HC-152F, HC-160F, HC-168F, HC-178F).These files are available at https://meps.ahrq.gov/mepsweb/data_stats/download_data_files.jsp.
The MSA variable is only available in the Public Use Files (PUFs) for 2011 and 2012 and is available through the AHRQ Data Center for 2013 and subsequent years.
Definitions
ExpendituresExpenditures include total direct payments from all sources to physicians and other types of health care providers (e.g., physical therapists, chiropractors, optometrists, etc.) for all medical events included in the office-based visits and outpatient department visits files.
Ambulatory care
Ambulatory care visits are defined as office-based provider visits and hospital outpatient visits, and VA care is defined based on source of payments for ambulatory care visits.
- Office-based provider visits: Visits to both physician and non-physician medical providers seen in office settings
- Hospital outpatient visits: Visits to both physicians and other medical providers seen in hospital outpatient departments, including payments for services covered under the basic facility charge and those for separately billed physician services
- VA ambulatory care: Any ambulatory care visit during the year for which there was a payment from the VA/CHAMPVA
- Non-VA ambulatory care: Any ambulatory care visit during the year for which there was no payment from the VA/CHAMPVA
Veterans are defined as persons who were reported as having been honorably discharged from active duty in the Armed Forces.
- Veterans who use only VA care: Those who have some payments made by VA/CHAMPVA for all their ambulatory care visits during the year
- Veterans who use only non-VA care: Those who have no payments made by VA/CHAMPVA for any of their ambulatory care visits during the year
- Veterans who use both VA and non-VA care: Those who have some payments made by VA/CHAMPVA for some, but not all, of their ambulatory care visits during the year
Individuals ages 18-64 were classified in the following three insurance categories, based on household responses to health insurance status questions:
- Any private health insurance: Individuals who, at any time during the year, had insurance that provided coverage for hospital and physician care (other than Medicare, Medicaid, or other public hospital/physician coverage) were classified as having private insurance. Coverage by TRICARE (Armed Forces-related coverage) was also included as private health insurance. Insurance that provided coverage for a single service only, such as dental or vision coverage, was not included.
- Public coverage only: Individuals were considered to have public coverage only if they met both of the following criteria: 1) They were not covered by private insurance at any time during the year; and 2) they were covered by any of the following public programs at any point during the year: Medicare, Medicaid, or other public hospital/physician coverage.
- Uninsured: The uninsured were defined as people not covered by private hospital/physician insurance, Medicare, TRICARE, Medicaid, or other public hospital/physician programs at any time during the entire year or period of eligibility for the survey.
- Out of pocket: This category includes expenses paid by the user or other family member.
- Private insurance: This category includes payments made by insurance plans covering hospital and medical care (excluding payments from Medicare, Medicaid, and other public sources). Payments from TRICARE (Armed Forces-related coverage) are also included.
- Public insurance: This category includes payments from Medicaid and CHIP, Medicare, other federal sources (Indian Health Service, military treatment facilities, and other care provided by the federal government), and various state and local sources (community and neighborhood clinics, state and local health departments, and state programs other than Medicaid/CHIP).
- VA: This category includes payments from the Department of Veterans Affairs (except TRICARE) and includes CHAMPVA.
- Other sources: This category includes payments from Workers' Compensation, various unclassified sources (e.g., automobile, homeowner's, or other liability insurance, and other miscellaneous or unknown sources), Medicaid/CHIP payments reported for persons who were not reported as enrolled in the Medicaid or CHIP programs at any time during the year, and private insurance payments reported for persons without any reported private health insurance coverage during the year.
Classification by race/ethnicity is based on information reported for each family member. First, respondents were asked if the person's main national origin or ancestry was Puerto Rican; Cuban; Mexican, Mexican-American, or Chicano; other Latin American; or other Spanish. All persons whose main national origin or ancestry was reported in one of these Hispanic groups, regardless of racial background, were classified as Hispanic. All other persons were classified according to their reported race. For this analysis, the following classification by race/ethnicity was used: Hispanic (any race), black non-Hispanic only, White/other.
About MEPS-HC
MEPS-HC is a nationally representative longitudinal survey that collects detailed information on health care utilization and expenditures, health insurance, and health status, as well as a wide variety of social, demographic, and economic characteristics for the U.S. civilian noninstitutionalized population. It is cosponsored by the Agency for Healthcare Research and Quality and the National Center for Health Statistics.For more information about MEPS, call the MEPS information coordinator at AHRQ (301) 427-1406 or visit the MEPS web site at http://www.meps.ahrq.gov/.
Suggested Citation
Bernard, D.M. and Fang Z. Ambulatory Care Use and Expenditures among Non-Elderly Veterans, 2011–2015. Research Findings #39. September 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://meps.ahrq.gov/mepsweb/data_files/publications/rf39/rf39.shtmlAHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of health care in the United States. We also invite you to tell us how you are using this Research Findings and other MEPS data and tools and to share suggestions on how MEPS products might be enhanced to further meet your needs. Please email us at MEPSProjectDirector@ahrq.hhs.gov or send a letter to the address below:
Joel W. Cohen, PhD, Director
Center for Financing, Access, and Cost Trends
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Characteristic |
All non-elderly Veterans | Veterans with any ambulatory care | Veterans with only VA ambulatory care | Veterans with only non-VA ambulatory care | Veterans with both VA and non-VA ambulatory care |
|---|---|---|---|---|---|
| Population (in thousands) | 9,653 (339) |
7,504 (295) |
1,068 (69) |
5,057 (217) |
1,378 (88) |
| Percentage of non-elderly Veterans | 100.0 - |
77.7 (0.9) |
11.1 (0.6) |
52.4 (1.0) |
14.3 (0.7) |
|
Source: Medical Expenditure Panel Survey-Household Component, 2011–2015 |
Characteristic |
Veterans with no ambulatory care visits | Veterans with only VA ambulatory care visits | Veterans with only non-VA ambulatory care visits | Veterans with both VA and non-VA ambulatory care visits |
|---|---|---|---|---|
| Age group | ||||
| Ages 18-39 | 29.6 (2.2) |
25.1 (2.3) |
17.7 a (1.3) |
15.3 a (2.3) |
| Ages 40-54 | 42.2 a (2.2) |
29.6 (2.5) |
41.5 a (1.3) |
36.7 c (2.8) |
| Ages 55-64 | 28.2 a (1.8) |
45.4 (2.8) |
40.9 (1.7) |
48.0 (2.8) |
| Sex | ||||
| Men | 91.2 (1.2) |
92.8 (1.4) |
87.0 a (1.2) |
84.7 a (1.8) |
| Women | 8.8 (1.2) |
7.2 (1.4) |
13.0 a (1.2) |
15.3 a (1.8) |
| Race/ethnicity | ||||
| Hispanic | 6.8 (1.0) |
7.9 (1.5) |
5.7 (0.7) |
9.6 (1.4) |
| Non-Hispanic black | 19.1 (1.6) |
22.6 (2.1) |
12.8 a (0.9) |
16.2 a (1.7) |
| White/other | 74.2 (1.8) |
69.5 (2.4) |
81.5 a (1.0) |
74.2 (2.1) |
| Perceived health | ||||
| Excellent health | 31.3 a (1.8) |
11.2 (1.9) |
20.9 a (1.3) |
12.1 (1.7) |
| Very good health | 35.3 (1.8) |
27.8 (2.4) |
37.2 a (1.4) |
28.5 (2.6) |
| Good health | 27.4 (1.7) |
35.0 (2.6) |
29.3 (1.4) |
32.2 (2.5) |
| Fair/poor health | 6.0 a (0.7) |
26.1 (2.4) |
12.6 a (1.0) |
27.2 (2.3) |
| Insurance status | ||||
| Any private | 71.5 b (2.0) |
63.3 (2.8) |
89.0 a (0.9) |
75.0 a (2.2) |
| Public only | 4.8 a (0.8) |
12.5 (1.8) |
5.0 a (0.5) |
15.1 (1.9) |
| Uninsured | 23.7 (1.9) |
24.2 (2.8) |
6.0 a (0.7) |
9.9 a (1.5) |
| Poverty status | ||||
| Poor/near poor or low income | 23.8 a (1.6) |
42.5 (2.7) |
13.7 a (0.8) |
26.8 a (2.2) |
| Middle income | 36.9 (2.0) |
35.5 (2.8) |
28.2 b (1.3) |
26.7 b (2.0) |
| High income | 39.3 a (2.2) |
22.0 (2.4) |
58.1 a (1.6) |
46.5 a (2.6) |
| Urbanicity | ||||
| MSA | 85.8 (1.8) |
78.0 (3.0) |
85.5 a (1.9) |
80.1 (2.6) |
| Non MSA | 14.2 (1.8) |
22.0 (3.0) |
14.5 a (1.9) |
19.9 (2.6) |
|
Source: Medical Expenditure Panel Survey-Household Component, 2011–2015 |
Characteristic |
Veterans with any ambulatory care visits | Veterans with only VA ambulatory care visits | Veterans with only non-VA ambulatory care visits | Veterans with both VA and non-VA ambulatory care visits |
|---|---|---|---|---|
| Number of ambulatory visits | 6.5 (0.3) |
6.9 (0.6) |
7.0 (0.3) |
14.8 a (0.8) |
| Number of VA ambulatory visits | 1.5 (0.1) |
6.9 (0.6) |
0 - |
5.5 b (0.5) |
| Number of non-VA ambulatory visits | 5.0 (0.2) |
0 - |
7.0 (0.3) |
9.3 c (0.6) |
|
Source: Medical Expenditure Panel Survey-Household Component, 2011–2015 |
Characteristic |
Veterans with any ambulatory care visits | Veterans with only VA ambulatory care visits | Veterans with only non-VA ambulatory care visits | Veterans with both VA and non-VA ambulatory care visits |
|---|---|---|---|---|
| Out-of-pocket | 8.5 (0.6) |
0.6 (0.1) |
12.3 a (1.0) |
5.5 a (0.9) |
| Veteran Affairs | 25.5 (2.6) |
91.0 (3.9) |
0 - |
41.0 a (3.9) |
| Private insurance | 51.9 (2.4) |
6.8 (4.4) |
73.4 a (2.2) |
35.7 a (3.0) |
| Public insurance | 8.7 (1.3) |
1.3 (0.6) |
9.0 a (1.6) |
10.6 a (2.3) |
| Other sources | 5.5 (0.9) |
0.4 (0.2) |
5.4 a (0.9) |
7.2 a (2.0) |
|
Source: Medical Expenditure Panel Survey-Household Component, 2011–2015 |
Characteristic |
Veterans with any ambulatory care visits | Veterans with only VA ambulatory care visits | Veterans with only non-VA ambulatory care visits | Veterans with both VA and non-VA ambulatory care visits |
|---|---|---|---|---|
| Total expenditures | 2,840 (197) |
2,279 (186) |
2,179 (167) |
5,697 a (868) |
| Out-of-pocket | 240 (14) |
14 (3) |
268 a (17) |
316 a (36) |
| Veteran Affairs | 724 (105) |
2,073 (175) |
0 - |
2,338 (532) |
| Private insurance | 1,473 (119) |
154 (103) |
1,600 a (153) |
2,032 a (362) |
| Public insurance | 246 (35) |
29 (13) |
195 a (34) |
602 a (111) |
| Other sources | 156 (26) |
9 (5) |
117 a (20) |
410 a (107) |
|
Source: Medical Expenditure Panel Survey-Household Component, 2011–2015 |
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