Cost-Shifting for Cardiovascular Hospitalizations Between Medicare Advantage and the Veterans Health Administration System

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among US veterans, many receiving cardiovascular care across both the Veterans Health Administration (VA) and non-VA hospitals, driven in part by the growth of Medicare Advantage (MA) enrollment. With both systems federally financed, overlapping payment responsibilities raise concern for duplicative federal spending on inpatient CVD care. METHODS: We conducted a national, cross-sectional study using 2021 linked MA and VA data to identify CVD hospitalizations defined using diagnosis-related groups among MA-enrolled veterans with VA benefits. Each CVD-related hospitalization (eg, heart failure exacerbation) was categorized by source of payment: MA-paid community hospital care, VA-paid community hospital care, or VA-direct care at VA hospitals. High-veteran plans were defined as ≥20% veteran enrollment. Multinomial logistic regressions were used to evaluate associations between high-veteran MA plan enrollment and payment source, adjusting for patient characteristics and state fixed effects. Analyses were stratified by admission complexity and elective status. RESULTS: Sample included 76 722 MA-enrolled veterans (mean [SD] age, 78.0 [8.8] years, 97.9% male), of which 10 366 (13.5%) were in high-veteran MA plans, and 66 356 (86.5%) were in high-veteran MA plans. Veterans in high-veteran MA plans were less likely to have MA-paid community hospitalizations than those in low-veteran MA plans (43.2% versus 69.2%; -26.1 percentage-points [95% CI, -27.1 to -25.1]) but more likely to have VA-paid community care (28.1% versus 16.0%; +12.2 percentage-points [95% CI, 11.3-13.0]) and VA-direct care (28.7% versus 14.8%; +13.9 percentage-points [95% CI, 13.0-14.8]). Results were consistent across admission types and medical complexity. CONCLUSIONS: Veterans enrolled in high-veteran MA plans were more likely to have inpatient CVD care financed by the VA, suggesting that MA plans may be shifting costs despite receiving capitated payments intended for inpatient care. Policy reforms are needed to reduce duplicative federal spending and improve coordination of cardiovascular care.