Effect of distance on urban and rural VA enrollees' use of VA and non-VA hospitalizations in four states

Objectives: Many Veterans Health Administration (VA) enrollees, particularly rural residents, use non-VA healthcare. We analyzed relative distances to, and the use of, VA and non-VA inpatient care by urban and rural enrollees in four states.

Methods: Using all hospitalizations that VA enrollees in Arizona, Iowa, Louisiana, or Florida underwent between 2004 and 2007 in either VA or non-VA hospitals, we separated unique veterans into those who used 1) VA hospitals only, 2) non-VA hospitals only, or 3) both. We calculated the difference in straight-line distances from each veteran's residence to the nearest VA hospital versus the nearest non-VA hospital. Within each state, we calculated proportions of users and average “VA-non-VA distance differences” in each group, for (RUCA-defined) urban and rural residents separately.

Results: Average admissions per veteran between 2004 and 2007 were similar across states: VA-only users averaged 2.0 admissions and non-VA-only users averaged 2.2 admissions, while those who used both systems averaged 3.6. Two-thirds of enrollees used non-VA hospitals only; this proportion was greater for rural than urban veterans in Arizona and Iowa, but less in Florida. In every state, the average VA-non-VA distance difference was greater for rural than urban veterans; the urban-rural discrepancy was small in Florida and greatest in Iowa and Arizona (70+ miles for rural Arizonians). For either urban or rural veterans in any state, the average VA-non-VA distance difference was smallest for VA-only users and greatest for non-VA only users, but this trend was as strong or stronger for urban than rural veterans.

Implications: Distance is an important factor in veterans' choices between VA and non-VA inpatient care, and in some states the distances that rural veterans must travel to VA care are great. For them, VA should seek to coordinate inpatient care options with non-VA hospitals.