Background: [The 2019 US Department of Health and Human Services Advancing American Kidney Health Initiative aims to “improve care coordination…for people living with kidney disease.” Accessing care from multiple systems and insurers can result in lapses in care coordination, and] patients with serious conditions, such as chronic kidney disease (CKD), are especially vulnerable to poorer outcomes from fragmented care. [While Medicaid expansion, as occurred with the Affordable Care Act (ACA),] is effective in improving access to health care and health outcomes for the uninsured, the significant number of Veterans enrolled in VA (who already have access to comprehensive care) who gained access to Medicaid with expansion face increased risk of care fragmentation. Increased use of non-VA care as a result of the MISSION Act poses similar risks.] Significance/Impact: As more Veterans access care from a mixture of VA and non-VA sources, VA needs to adopt strategies for cross-system care coordination to ensure effective and efficient care for Veterans. This requires understanding how Veterans utilize care when multiple options are available. Patients with advanced CKD have highly complex care needs. Lack of well-coordinated care may increase unnecessary care and worsen outcomes for such patients. Examining use and outcomes data will illustrate multiple aspects of access and care coordination for Veterans with chronic conditions and anticipates implementation of the MISSION Act. Innovation: [That some states opted out of ACA Medicaid expansion allows for a natural experiment where changes in quality of care and utilization over time can be compared between states that did and did not expand Medicaid. The team will use VA, Medicare, and recently-released post-expansion Medicaid claims data to evaluate how Medicaid expansion influences Veteran choices of health system use and CKD treatment.] Specific Aims: Aim 1: To determine the characteristics of Veterans and Veterans with CKD who are most likely to enroll in both Medicaid and VA. Aim 2: To determine the impact of dual enrollment on the utilization of health care services for Veterans with advanced CKD and to create a reference tool to enhance coordination for these patients. Aim 3: To evaluate differences in quality of health care and costs among Veterans with advanced CKD in states that have expanded Medicaid and those that have not. Methodology: Claims data [from 17 states (7 that expanded Medicaid in 2014 and 10 that did not) in the Medicaid Analytic eXtract (MAX) file for 2011-2014] are included. A difference-in-difference model will estimate the association of state Medicaid expansion with [changes in Veterans’ dual-enrollment status (VA and Medicaid) and in utilization and outcomes for Veterans with CKD. Utilization analyses will consider outpatient visits, emergency department visits and hospital admissions recorded in VA and Medicaid data. Outcomes to be considered are time-to-mortality, emergent vs. elective initiation of dialysis, and costs to the health care system.] Each analysis contains demographics, comorbidity and illness severity. For all aims, separate models for low-income (Priority 5) Veterans are estimated as a sensitivity check. [In addition, strategies to support enhanced care coordination will be gathered from interviews with renal care teams and organizational leaders then developed into a care coordination reference tool for those who provide care for patients with kidney disease. Input from Veterans and patients will be incorporated at each stage of the interview and reference tool development process. Next Steps/Implementation: Veteran/patient and VA operational (National Kidney Program; Office of Veterans Access to Care) partners will be provided with interim and final findings to guide strategic planning and to inform programs that support optimal care for Veterans with access to multiple sources of care. Results from this project will be of great importance as stakeholders plan for Veteran needs in the form of direct health care services and effective care coordination, and as they make state and national policy recommendations.]

Veterans who access health care from multiple systems are at risk of experiencing fragmented care. Fragmented care can lead to feelings of mistrust, abandonment, and isolation. Fragmentation created by dual use of VA and non-VA services creates inefficiency, unnecessary care, and worse outcomes. The 2018 MISSION Act and Medicaid expansion under the ACA result in more health care options for Veterans, but also increased risk of fragmented care. We will assess choices Veterans made about their care after Medicaid expansion. We will focus on a group particularly vulnerable to fragmented care–patients with complex health care needs from advanced chronic kidney disease. As VA incorporates more non-VA sources of care under the MISSION Act, understanding trade-offs between increasing access and ensuring high quality, coordinated care will become a central question for VA. Understanding how Veterans choose to access care when given multiple options is key to making health system improvements in resource deployment and care coordination.