Comprehensive support for family caregivers of post-/11 veterans in the United States: Impact on veteran health care utilization and costs
Courtney Van Houtven | Duke University and Department of Veterans Affairs
Objective: The United States Department of Veterans Affairs (VA) provides health care to 9 million Veterans in the United States. Mandated by law in 2010, The VA Program of Comprehensive Assistance for Family Caregivers (The Comprehensive Program) supports informal caregivers who care for Veterans who were seriously injured on or after September 11, 2001 while serving in the US Armed Forces and who need assistance with Activities of Daily Living or supervision or protection because of the residual effects of their injuries including traumatic brain injury, psychological trauma or other mental disorder. The Program offers a series of services and supports for the caregiver, such as health insurance, education and training, travel, lodging and subsistence, respite care and caregiver mental health services. Importantly, participating caregivers receive a direct monthly stipend ranging from $600-$2300. As part of a larger evaluation, the objective in this paper was to evaluate the early impact of the Comprehensive Program on Veteran health care utilization and costs (2011-2014).
Data: Application data; electronic health record data from the Veterans Health Administration (VHA).
Methods: A pre-post cohort design including a non-equivalent control group was used to understand how Veterans’ acute care (emergency department, hospital care), outpatient care (primary, specialty, mental health care), and total costs changed in six month intervals 0-36 months after enrolment in the program. The control group is an inverse-propensity-score weighted sample of Veterans whose caregivers applied for but were not accepted into the program. The approach obtains the estimated average treatment effect among the treated (ATT).
Results: Enrolled Veterans had similar acute care utilization 0-36 months post application from those in the control group, but significantly greater primary care and mental health outpatient care use 0-36 post, and significantly greater specialty care use 0-30 months post. Estimated total costs for Veterans of enrolled caregivers were $1500-$3500 higher per six month interval 0-36 months post.
Policy implications: The Comprehensive Program was associated with increased outpatient care but not associated with increased acute care use. Increasing access to care for Veterans is a priority of the Department of Veterans Affairs, as detailed in its Blueprint for Excellence (VHA 2014). The increased outpatient utilization could be attributed to increased access to care that is facilitated by enhanced caregiver support, or it could be that treated Veterans have increased need for outpatient care. Future work should examine longer term utilization and specific subtypes of utilization (e.g., psychiatric inpatient admissions) to provide an understanding of whether increased utilization of outpatient mental health care in the short term leads to lower utilization of emergency and/or acute care for mental health in the longer term. Examination of longer term outcomes could provide a better picture of the long-term return on investment to the Veterans Health Administration.