title: Veterans Health Administration and Medicare outpatient health care utilization by older rural and urban New England veterans.
abstract: BACKGROUND
  Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services.
  
  
  OBJECTIVE
  The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England.
  
  
  METHODS
  The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care.
  
  
  RESULTS
  Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care.
  
  
  CONCLUSIONS
  These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.
authors.affiliation: Department of Psychiatry, Medicine, Dartmouth Medical School, Hanover, NH, USA. william.b.weeks@dartmouth.edu
authors.forename: William B
authors.initials: WB
authors.lastname: Weeks
authors.forename: David M
authors.initials: DM
authors.lastname: Bott
authors.forename: Rebecca P
authors.initials: RP
authors.lastname: Lamkin
authors.forename: Steven M
authors.initials: SM
authors.lastname: Wright
mesh_terms: D000368:Aged; D002391:Catchment Area, Health; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data*; D008511:Medicine; D009511:New England / Q000453:epidemiology; D011320:Primary Health Care; D019035:Rural Health Services / Q000706:statistics & numerical data*; D013038:Specialization; D014481:United States; D014493:United States Department of Veterans Affairs; D019037:Urban Health Services / Q000706:statistics & numerical data*; D014728:Veterans / Q000706:statistics & numerical data*