Does Membership in Veterans' Service Organizations Influence Use of the Department of Veterans Affairs as the Usual Source of Care?

Military Medicine, Sep 2004 by Harada, Nancy D, Pourat, Nadereh

Veterans' service organizations (VSOs) provide outreach regarding veterans' benefits. Medical care provided by the Department of Veterans Affairs (VA) is one such benefit that has improved health and quality of life. This study evaluates the characteristics of veterans who report VSO membership and who use the VA as their usual source of care, and it determines whether VSO membership influences the choice of a VA or non-VA facility as the usual source of care. The findings reveal that VSO members, compared with nonmembers, are Caucasian, older, retired, of lower income, and more functionally impaired. Veterans who use the VA, compared with non-VA users, are African American, of lower income, unemployed, and more functionally impaired. VSO members are more likely to use the VA as the usual source of care than are VSO nonmembers, with the effects varying according to race/ethnicity. Policy recommendations include increasing the diversity of VSO membership, because VSOs play an important outreach and informational role for veterans.

Introduction

Veterans' service organizations (VSOs) play an important role in the lives of U.S. veterans. VSOs aim to improve veterans' quality of life through direct assistance, such as applying for benefits or providing transportation to Veterans Affairs (VA) health care facilities. At a national policy level, VSO representatives may propose legislation, lobby Congress, and provide testimony on proposed legislation. One VSO success was the GI Bill of Rights, which was originally drafted by the American Legion in 1943 and eventually led to the establishment of the VA. Recently, the American Legion drafted the GI Bill of Health, which would open the VA health care system to all of the nation's veterans and their families.

Despite the strong involvement of VSOs in promoting veterans services, few studies have explored whether they actually influence veteran health care-seeking behavior. In a recent study of 2,652 veterans, Harada et al.1 found VSO members to be more than twice as likely as nonmembers to prefer VA facilities for their health care. That study examined veterans' preferences for care and did not examine whether VSO membership influenced the usual source of care, e.g., where a veteran obtains medical care on a regular basis.2

Numerous studies have documented the importance of having a usual source of care.3"8 Compared with not having a usual source of care, some of the advantages of having a usual source of care are greater likelihood of receiving preventive health services such as cholesterol level and blood pressure checks,6,9 a greater likelihood of being diagnosed early and receiving appropriate care for illnesses, and greater satisfaction with care.4,10 One study comparing veterans who received 90% of their care from VA facilities with their counterparts who received 90% of their care outside VA facilities found that veterans who received the majority of their care from VA facilities obtained more preventive services.9 Similarly, Piette10 compared diabetic patients served by the VA or by county-funded health systems and they found that VA facility patients received more preventive counseling, eye examinations, and cholesterol tests than did county-funded system patients.

To better understand the relationship between VSO membership and the usual source of care among the veteran population, we sought to (1) describe the characteristics of veterans who report VSO membership, (2) describe the characteristics of veterans who use the VA as their usual source of care, and (3) determine whether VSO membership influences whether veterans use the VA as their usual source of ambulatory care. IfVSO membership is found to influence veterans' choices regarding the usual source of ambulatory care, then the VA can confidently pursue outreach activities with VSOs that might have major effects on veterans' decisions to seek care at VA facilities. We hypothesize that VSOs significantly influence whether veterans use the VA as their usual source of ambulatory care.

The theoretical framework guiding this study is the Behavioral Model of Health Care Utilization.11 This model describes predictors of utilization as predisposing (age and gender), enabling (income and insurance), or need (health status). VSOs are categorized as enabling variables because they may affect where a veteran seeks health care.

Methods

Data

The data for this study came from the 2001 Veteran Identity Program Survey that was designed to measure the use of outpatient care by veterans. The survey was administered via telephone to veterans living in Veterans Integrated Service Network 22 (VISN 22), covering southern California and southern Nevada, between November 2000 and February 2001.

Male veterans were included in the sample if they had been honorably discharged from the military. Potential respondent VA users were randomly identified through patient lists, maintained by each VISN 22 VA facility, of veterans who had used any VA service during fiscal year 2000. VA nonusers were identified through random-digit dialing with a set of all listed and unlisted numbers in area code/exchange combinations for VISN 22 counties. A sampling method described by Casady and Lepkowski12 was used to generate two strata for each county, on the basis of the number of listed residential numbers, i.e., a low-density stratum and a high-density stratum. The percentage of working residential telephone numbers in the low-density stratum was only approximately 2%, whereas the corresponding percentage in the high-density stratum was approximately 52%. The Casady-Lepkowsky approach draws a random-digit dialing sample from the high-density stratum, where the "hit" rate is much higher.