Mehtsun Winta T, Ma Yanlei, Latsko Ellen, Zheng Jie, Phelan Jessica, Orav E John, Tsai Thomas C, Frakt Austin B, Pizer Steven D, Garrido Melissa M, Figueroa Jose F
Department of Surgery, University of California, San Diego.
Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
JAMA Health Forum. 2025 Jun 7;6(6):e250827. doi: 10.1001/jamahealthforum.2025.0827.
There is growing concern that Medicare Advantage (MA) plans are shifting the costs of care to the Veterans Health Administration (VHA) for veterans dually enrolled in both systems, particularly in high-veteran MA plans that disproportionately enroll veterans. However, empirical evidence evaluating the sources of payment for veterans' surgical care is lacking.
To evaluate differences in payment sources for surgical care between high-veteran MA plans and other MA plans.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used 2021 US national MA and VHA data from veterans dually enrolled in MA and VHA care for inpatient surgical episodes at VHA facilities (VHA-paid direct care), non-VHA community hospitals paid by VHA (VHA-paid community care), and community hospitals paid by MA (MA-paid community care) among veterans dually enrolled in MA and VHA care. Data were analyzed from April 1, 2024, to November 30, 2024.
Enrollment in high-veteran MA plans.
Likelihood of utilizing VHA-direct care, VHA-paid community care, and MA-paid community care. High-veteran MA plans were defined as plans with 20% or more veteran enrollees; others were categorized as other MA plans. Multinomial logistic regression was used to evaluate the association of veteran enrollment in high-veteran MA plans with the likelihood of surgical care paid by each payment source, adjusting for veteran and surgery characteristics, and state fixed effects. Stratified analyses were conducted based on surgical complexity and source of admission.
A total of 54 754 inpatient surgical episodes were analyzed, including 53 036 male (96.9%); 3133 Hispanic (5.7%), 47344 non-Hispanic Black (13.4%), 2933 non-Hispanic White (78.4%), and 1354 other or unknown race and ethnicity (2.5%); 601 (1.1%) were younger than 55 years, 3301(6.0%) aged 55 to 64 years, 22 381 (40.9%) aged 65 to 74 years, and 28471 (52%) aged 75 or older. Among these episodes, 52.1% were through MA-paid community care, 18.8% through VHA-direct care, and 29.1% through VHA-paid community care. Veteran enrollees in high-veteran MA plans were significantly less likely to have MA-paid surgeries (adjusted difference, -25.7 percentage points; 95% CI, -26.7 to 24.6 percentage points) and more likely to have surgeries paid through VHA-direct care (adjusted difference, 11.0 percentage points; 95% CI, 10.0-12.0 percentage points) and VHA-paid community care (adjusted difference, 14.7 percentage points; 95% CI, 13.6-15.8 percentage points) compared with veterans in other MA plans. As surgical complexity increased, differences in the use of VHA-paid direct care narrowed between high-veteran MA and other MA plans. Payment source differences were also less pronounced for nonelective surgeries admitted through emergency departments.
The findings of this cross-sectional study suggest substantial cost shifting in veterans' surgical care from MA to VHA among high-veteran MA plans, underscoring the urgent need for policy reforms to improve the efficiency of veterans' care.
人们越来越担心医疗保险优势（MA）计划正在将护理成本转嫁给同时加入这两个系统的退伍军人的退伍军人健康管理局（VHA），特别是在退伍军人比例过高的高退伍军人MA计划中。然而，缺乏评估退伍军人手术护理支付来源的实证证据。
评估高退伍军人MA计划与其他MA计划在手术护理支付来源上的差异。
设计、设置和参与者：这项横断面研究使用了2021年美国全国MA和VHA的数据，这些数据来自同时加入MA和VHA护理的退伍军人，用于VHA设施的住院手术事件（VHA支付的直接护理）、由VHA支付的非VHA社区医院（VHA支付的社区护理）以及由MA支付的社区医院（MA支付的社区护理）。数据于2024年4月1日至2024年11月30日进行分析。
加入高退伍军人MA计划。
使用VHA直接护理、VHA支付的社区护理和MA支付的社区护理的可能性。高退伍军人MA计划被定义为退伍军人参保率达到20%或更高的计划；其他计划则归类为其他MA计划。使用多项逻辑回归来评估退伍军人加入高退伍军人MA计划与每种支付来源支付手术护理的可能性之间 的关联，并对退伍军人和手术特征以及州固定效应进行调整。根据手术复杂性和入院来源进行分层分析。
共分析了54754例住院手术事件，其中男性53036例（96.9%）；西班牙裔3133例（5.7%），非西班牙裔黑人47344例（13.4%），非西班牙裔白人2933例（78.4%），其他或种族和族裔不明者1354例（2.5%）；601例（1.1%）年龄小于55岁，3301例（6.0%）年龄在55至64岁之间，22381例（40.9%）年龄在65至74岁之间，28471例（52%）年龄在75岁及以上。在这些事件中，52.1%通过MA支付的社区护理，18.8%通过VHA直接护理，29.1%通过VHA支付的社区护理。与其他MA计划中的退伍军人相比，加入高退伍军人MA计划的退伍军人接受MA支付手术的可能性显著降低（调整差异为-25.7个百分点；95%置信区间为-26.7至-24.6个百分点），而通过VHA直接护理（调整差异为11.0个百分点；95%置信区间为10.0-12.0个百分点）和VHA支付的社区护理（调整差异为14.7个百分点；95%置信区间为13.6-15.8个百分点）支付手术的可能性更高。随着手术复杂性的增加，高退伍军人MA计划与其他MA计划在使用VHA支付的直接护理方面的差异缩小。通过急诊科入院的非选择性手术的支付来源差异也不太明显。
这项横断面研究的结果表明，在高退伍军人MA计划中，退伍军人手术护理的成本大量从MA转移到了VHA，这突出了进行政策改革以提高退伍军人护理效率的迫切需要。
