Abstract

“Many veterans receive care from both the Veterans Health Administration (VHA) and the non-VHA health system, or dual care. Non-federal physicians practicing in Nebraska were surveyed to examine their perspectives on the organization and delivery of dual care provided to veterans. A paper-based survey was mailed to all 1,287 non-federal primary care physicians (PCPs) and a purposive sample of 765 specialist physicians practicing in Nebraska. Rural physicians are more likely to incorporate care coordination practices in their clinical practice, compared to urban physicians. More rural physicians report difficulties in patient transfers, and referrals to the VHA, in prescribing for veteran patients, and in contacting a VHA provider in an emergent situation regarding their veteran patient. More PCPs also report difficulties in referrals to the VHA. However, more rural and primary care physicians follow up with their veteran patients post referral to the VHA. There was agreement among the physicians that the current dual care system needed improvements to provide timely, efficient, coordinated and high quality care to veterans. The specific areas identified for improvement were coordination of care, information sharing, medication management, streamlining of patient transfers, reimbursement for care provided outside the VA, and better delineation and clarity of the boundaries of each system and roles and responsibilities of VA and non-VA providers in the care of veterans.”

Implications

For Practice

Since VHA services are limited, veterans are increasingly seeking the services of non-VHA physicians in rural areas. Depending on the specifics of the situation, most non-VHA physicians are able to address veterans’ general health care needs and most service-related conditions. A dual system, which blends non-VHA and VHA services, allows veterans to use Medicare and VHA benefits toward the costs of medical services. However, there can be problems if services are not coordinated between the two systems. When care is not well-coordinated, studies indicate that patient outcomes are worse than they would be with a single provider. If patients choose to use a dual system of care, physicians should work to develop a written co-management plan. Co-management plans should detail what each physician plans to provide in terms of services and communication. In this study, rural doctors and primary care doctors report that their efforts to work cooperatively with the VHA services are hampered by poor VHA communication, problems with patient transfers and difficulties with reimbursement for services. It is especially important for patients to notify non-VHA physicians when the VHA physician makes changes to the patient’s medications, such as generic medications or other substitutions, as the prescribing physician may not find substitutions as effective in patient treatment. Veterans can support their own care by keeping records of appointments, medications, tests and treatments in a folder with the co-management plan. The patient should carry a copy of his/her own records and co-management plans to each appointment with any provider to actively support communication between their dual care physicians, especially in the event that a patient needs emergency care from a new provider.

For Policy

VA policy makers should work with non-VHA physician organizations to craft clear expectations about the limitations of each medical system and a better explanation of the roles and responsibilities of VHA and non-VHA physicians. Medical professionals should improve communication among VHA and non- VHA providers and consider the use of written, formal co-management plans to coordinate care. Professionals should create guidelines regarding the format of medical records to allow for an efficient summary of critical information attached to the patient’s complete record. Healthcare Administrators can support the implementation of Electronic Medical Records (EMR) compatible across medical service systems. Additionally, the VHA’s pharmacy system information should be accessible to non-VHA providers. This will allow non-VHA doctors to write prescriptions for their patients, which can be filled using their VA benefits.

For Future Research

This survey was sent to 2,052 physicians in Nebraska. A total of 383 physicians responded to this paper-based survey. Because a low response rate can create some bias in results, consideration should be given to improving response rates in future studies on this topic. It may be helpful to use electronic surveys to collect more information or to survey audiences at a professional event where the time constraints of office hours are removed. The survey asked 54 closed and open-ended questions and its length may have discouraged some physicians from responding, so careful attention should be paid to survey construction. New research could provide information about the availability and compatibility of EMR between VHA systems and all non-VHA providers. Additionally, these survey results indicate that the VHA pharmacy system has created problems for 73.1 of all responding non-VHA physicians. Further research as to the precise nature of substitutions for prescribed medications could assist the VHA to expand the list of available medications in a cost-effective and efficient manner.