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Decades of research shows that small firms are much less likely to offer health insurance than large firms, but less is known about differences among small employers. We examine this issue using the Medical Expenditure Panel Survey-Insurance Component with Administrative Records (MEPS-ICAR), a unique employer-employee linked data set that is constructed by matching the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC) to Internal Revenue Service administrative records and the Decennial Census. Multivariate analyses show that among firms with fewer than 50 workers, the probability that workers receive an insurance offer is positively associated with higher median workforce incomes, and conditional offers of dependent coverage increase when the majority of workers are married or from a family with at least three members. This first application of the MEPS-ICAR highlights the significance of workforce characteristics in shaping small employer insurance benefits and the data's usefulness for expanding analyses of policy changes, wage-benefit tradeoffs, and health insurance benefits., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Obtaining health insurance coverage has historically been challenging for workers at small firms and the self-employed. Using data from the Medical Expenditure Panel Survey, we found that the overall uninsurance rate for these workers and their families declined by 5 percentage points over the past decade, but one-third of those with lower incomes remained uninsured in 2014-15.

Over the past decade, employers have increasingly turned to high-deductible health plans (HDHPs) to limit health insurance premium growth. We used data from private-sector establishments for 2006 and 2016 from the Medical Expenditure Panel Survey-Insurance Component to examine trends in HDHP enrollment and heterogeneity in HDHPs by firm size. We studied insurance plan offerings along the following dimensions: whether employers fund accounts to help defray employees' out-of-pocket health care spending, the availability of non-HDHP plan choices, and single and family deductible levels. We extend the literature by examining these characteristics by detailed firm-size categories and by including all plans with deductibles that met or exceeded Internal Revenue Service thresholds to be qualified for health savings accounts. We found that in 2016, 78.0 percent of HDHP enrollees in the smallest firms (those with fewer than 25 employees) lacked an employer-funded account, compared to 35.2 percent in the largest firms (those with 1,000 or more employees). Overall, HDHP enrollees in the largest firms had significant advantages relative to workers in smaller firms along all of the dimensions examined.

Importance: The Centers for Medicare & Medicaid Services publicly reports hospital 30-day, all-cause, risk-standardized mortality rates (RSMRs) and 30-day, all-cause, risk-standardized readmission rates (RSRRs) for acute myocardial infarction, heart failure, and pneumonia. The evaluation of hospital performance as measured by RSMRs and RSRRs has not been well characterized., Objective: To determine the relationship between hospital RSMRs and RSRRs overall and within subgroups defined by hospital characteristics., Design, Setting, and Participants: We studied Medicare fee-for-service beneficiaries discharged with acute myocardial infarction, heart failure, or pneumonia between July 1, 2005, and June 30, 2008 (4506 hospitals for acute myocardial infarction, 4767 hospitals for heart failure, and 4811 hospitals for pneumonia). We quantified the correlation between hospital RSMRs and RSRRs using weighted linear correlation; evaluated correlations in groups defined by hospital characteristics; and determined the proportion of hospitals with better and worse performance on both measures., Main Outcome Measures: Hospital 30-day RSMRs and RSRRs., Results: Mean RSMRs and RSRRs, respectively, were 16.60% and 19.94% for acute myocardial infarction, 11.17% and 24.56% for heart failure, and 11.64% and 18.22% for pneumonia. The correlations between RSMRs and RSRRs were 0.03 (95% CI, -0.002 to 0.06) for acute myocardial infarction, -0.17 (95% CI, -0.20 to -0.14) for heart failure, and 0.002 (95% CI, -0.03 to 0.03) for pneumonia. The results were similar for subgroups defined by hospital characteristics. Although there was a significant negative linear relationship between RSMRs and RSRRs for heart failure, the shared variance between them was only 2.9% (r2 = 0.029), with the correlation most prominent for hospitals with RSMR <11%., Conclusion and Relevance: Risk-standardized mortality rates and readmission rates were not associated for patients admitted with an acute myocardial infarction or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure.

While substantial research examines the dynamics prompting policy adoption, few studies have assessed whether enacted policies are modified to meet distributional equity concerns. Past research suggests that important forces limit such adaptation, termed here "policy inertia." We examine whether block grant allocations to states from the Ryan White HIV/AIDS Program have evolved in response to major technological and political changes. We assess the impact of initial allocations on later funding patterns, compared to five counterfactual distributional equity standards. Initial allocations strongly predict future allocations; in comparison, the standards are weak predictors, suggesting the importance of policy inertia. Our methodology of employing multiple measures of equity as a counterfactual to policy inertia can be used to evaluate the adaptability of federalist programs in other domains.

Context: Whether decreases in the length of stay during the past decade for patients with heart failure (HF) may be associated with changes in outcomes is unknown., Objective: To describe the temporal changes in length of stay, discharge disposition, and short-term outcomes among older patients hospitalized for HF., Design, Setting, and Participants: An observational study of 6,955,461 Medicare fee-for-service hospitalizations for HF between 1993 and 2006, with a 30-day follow-up., Main Outcome Measures: Length of hospital stay, in-patient and 30-day mortality, and 30-day readmission rates., Results: Between 1993 and 2006, mean length of stay decreased from 8.81 days (95% confidence interval [CI], 8.79-8.83 days) to 6.33 days (95% CI, 6.32-6.34 days). In-hospital mortality decreased from 8.5% (95% CI, 8.4%-8.6%) in 1993 to 4.3% (95% CI, 4.2%-4.4%) in 2006, whereas 30-day mortality decreased from 12.8% (95% CI, 12.8%-12.9%) to 10.7% (95% CI, 10.7%-10.8%). Discharges to home or under home care service decreased from 74.0% to 66.9% and discharges to skilled nursing facilities increased from 13.0% to 19.9%. Thirty-day readmission rates increased from 17.2% (95% CI, 17.1%-17.3%) to 20.1% (95% CI, 20.0%-20.2%; all P < .001). Consistent with the unadjusted analyses, the 2005-2006 risk-adjusted 30-day mortality risk ratio was 0.92 (95% CI, 0.91-0.93) compared with 1993-1994, and the 30-day readmission risk ratio was 1.11 (95% CI, 1.10-1.11)., Conclusion: For patients admitted with HF during the past 14 years, reductions in length of stay and in-hospital mortality, less marked reductions in 30-day mortality, and changes in discharge disposition accompanied by increases in 30-day readmission rates were observed.

Background: The Centers for Medicare & Medicaid Services (CMS) readmission measure is based on all-cause readmissions to any hospital within 30 days of discharge. Whether a measure based on same-hospital readmission, an outcome that is easier for hospitals and some systems to track, could serve as a proxy for the all-hospital measure is not known., Objectives: Evaluate whether same-hospital readmission rate is a good surrogate for all-hospital readmission rate., Research Design: The study population was derived from the Medicare inpatient, outpatient, and carrier (physician) Standard Analytic Files. Thirty-day risk-standardized readmission rates (RSRRs) for heart failure (HF) for both all-hospital readmission and same-hospital readmission were assessed by using hierarchical logistic regression models., Subjects: The sample consisted of 501,234 hospitalizations in 4674 hospitals with at least 1 hospitalization., Measures: Thirty-day readmission was defined as occurrence of at least 1 hospitalization in any US acute care hospital for any cause within 30 days of discharge after an index hospitalization. Same-hospital readmission was considered if the patient was admitted to the hospital that produced the original discharge within 30 days., Results: Overall, 80.9% of all HF readmissions occurred in the same- hospital, whereas 19.1% of readmissions occurred in a different hospital. The mean difference between all- versus same-hospital RSRR was 4.7 +/- 1.0%, ranging from 0.9% to 10.5% across these hospitals with 25th, 50th, and 75th percentiles of 4.1%, 4.7%, and 5.2%, respectively, and was variable across the range of average RSRR., Conclusion: Same-hospital readmission rate is an unreliable and biased indicator of all-hospital readmission rate with limited value as a benchmark for quality of care processes.

Background: The association between hospital volume and the death rate for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia remains unclear. It is also not known whether a volume threshold for such an association exists., Methods: We conducted cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries who were hospitalized between 2004 and 2006 in acute care hospitals in the United States for acute myocardial infarction, heart failure, or pneumonia. Using hierarchical logistic-regression models for each condition, we estimated the change in the odds of death within 30 days associated with an increase of 100 patients in the annual hospital volume. Analyses were adjusted for patients' risk factors and hospital characteristics. Bootstrapping procedures were used to estimate 95% confidence intervals to identify the condition-specific volume thresholds above which an increased volume was not associated with reduced mortality., Results: There were 734,972 hospitalizations for acute myocardial infarction in 4128 hospitals, 1,324,287 for heart failure in 4679 hospitals, and 1,418,252 for pneumonia in 4673 hospitals. An increased hospital volume was associated with reduced 30-day mortality for all conditions (P<0.001 for all comparisons). For each condition, the association between volume and outcome was attenuated as the hospital's volume increased. For acute myocardial infarction, once the annual volume reached 610 patients (95% confidence interval [CI], 539 to 679), an increase in the hospital volume by 100 patients was no longer significantly associated with reduced odds of death. The volume threshold was 500 patients (95% CI, 433 to 566) for heart failure and 210 patients (95% CI, 142 to 284) for pneumonia., Conclusions: Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality., (2010 Massachusetts Medical Society)

Background: Prior research identified variations in care experiences across Medicare health plans (Medicare Advantage [MA]), but the relative amount of variation in MA and traditional fee-for-service (FFS) Medicare is unknown., Objectives: Compare variation and correlations of beneficiary reports of care experiences across geographic areas in MA and FFS., Methods: Using the 2001 to 2004 Medicare CAHPS surveys, we analyzed 14 measures of care experiences and preventive services reported by 433,092 MA beneficiaries (82% response rate) and 244,731 in FFS (69% response rate). We estimated hierarchical regression models with random effects for state, hospital referral region, and plan, adjusting for respondent characteristics. We examined the relative variation in FFS and MA scores across areas and among individual MA plans, the correlation between FFS and MA scores across areas, and variability relative to average MA-FFS differences in scores., Results: Although MA and FFS scores are highly correlated, variation is greater in MA than FFS across states and local areas for almost all measures. MA plan variation within areas accounts for 25% to 50% of explained MA variation. MA-FFS differences are smaller than the standard deviations of differences across areas for 10 of 14 measures., Conclusions: Relative performance between MA and FFS may differ across areas and locally between individual plans and FFS. Quality improvement initiatives should address local system factors that affect both MA and FFS, and identify organizational factors that make some MA plans more successful in improving quality.

Background: In July 2009, Medicare began publicly reporting hospitals' risk-standardized 30-day all-cause readmission rates (RSRRs) among fee-for-service beneficiaries discharged after hospitalization for heart failure from all the US acute care nonfederal hospitals. No recent national trends in RSRRs have been reported, and it is not known whether hospital-specific performance is improving or variation in performance is decreasing., Methods and Results: We used 2004-2006 Medicare administrative data to identify all fee-for-service beneficiaries admitted to a US acute care hospital for heart failure and discharged alive. We estimated mean annual RSRRs, a National Quality Forum-endorsed metric for quality, using 2-level hierarchical models that accounted for age, sex, and multiple comorbidities; variation in quality was estimated by the SD of the RSRRs. There were 570 996 distinct hospitalizations for heart failure in which the patient was discharged alive in 4728 hospitals in 2004, 544 550 in 4694 hospitals in 2005, and 501 234 in 4674 hospitals in 2006. Unadjusted 30-day all-cause readmission rates were virtually identical over this period: 23.0% in 2004, 23.3% in 2005, and 22.9% in 2006. The mean and SD of RSRRs were also similar: mean (SD) of 23.7% (1.3) in 2004, 23.9% (1.4) in 2005, and 23.8% (1.4) in 2006, suggesting similar hospital variation throughout the study period., Conclusions: National mean and RSRR distributions among Medicare beneficiaries discharged after hospitalization for heart failure have not changed in recent years, indicating that there was neither improvement in hospital readmission rates nor in hospital variations in rates over this time period.

Background: The rankings of "America's Best Hospitals" by U.S. News & World Report are influential, but the performance of ranked hospitals in caring for patients with routine cardiac conditions such as heart failure is not known., Methods and Results: Using hierarchical regression models based on medical administrative data from the period July 1, 2005, to June 30, 2006, we calculated risk-standardized mortality rates and risk-standardized readmission rates for ranked and nonranked hospitals in the treatment of heart failure. The mortality analysis examined 14 813 patients in 50 ranked hospitals and 409 806 patients in 4761 nonranked hospitals. The readmission analysis included 16 641 patients in 50 ranked hospitals and 458 473 patients in 4627 nonranked hospitals. Mean 30-day risk-standardized mortality rates were lower in ranked versus nonranked hospitals (10.1% versus 11.2%, P<0.01), whereas mean 30-day risk-standardized readmission rates were no different between ranked and nonranked hospitals (23.6% versus 23.8%, P=0.40). The 30-day risk-standardized mortality rates varied widely for both ranked and nonranked hospitals, ranging from 7.9% to 12.4% for ranked hospitals and from 7.1% to 17.5% for nonranked hospitals. The 30-day risk-standardized readmission rates also spanned a large range, from 18.7% to 29.3% for ranked hospitals and from 19.2% to 29.8% for nonranked hospitals., Conclusions: Hospitals ranked by U.S. News & World Report as "America's Best Hospitals" in "Heart & Heart Surgery" are more likely than nonranked hospitals to have a significantly lower than expected 30-day mortality rate, but there was much overlap in performance. For readmission, the rates were similar in ranked and nonranked hospitals.

Background: The Centers for Medicare & Medicaid Services pays for services provided through traditional fee-for-service (FFS) Medicare and managed care plans (Medicare Advantage [MA]). It is important to understand how financing and organizational arrangements relate to quality of care., Objectives: To compare care experiences and preventive services receipt in traditional Medicare and MA for healthy and sick beneficiaries., Methods: Randomly selected beneficiaries responded to the 2003 and 2004 Consumer Assessments of Healthcare Providers and Systems (CAHPS(R)) surveys. We analyzed 237,221 MA responses (80% response rate) and 153,535 from FFS (68% response rate). We compared case-mix-adjusted CAHPS scores between FFS and MA for healthy and sick beneficiaries on 7 CAHPS measures of care experiences and 3 preventive service measures., Results: CAHPS scores were lower in MA than FFS for all care experience measures except office wait time. The sick had less favorable care experiences than the healthy for all measures, but were more likely to receive each preventive service (P < 0.001). FFS-MA differences were larger for the sick than the healthy for 5 of 7 experience measures (P < 0.05), and were twice as large for physician ratings and interactions. Office wait time and rates of immunization were better in MA than FFS (P < 0.001), with no differences between healthy and sick groups., Conclusions: Beneficiaries in health plans report less favorable care experiences than those in FFS, particularly among the sick, but preventive service measures are higher in MA. The Centers for Medicare and Medicaid Services should strengthen efforts to improve care experiences of the sick, particularly in MA, and preventive service receipt in FFS.

Background: Smoking and patterns of diet and activity are the 2 leading underlying causes of death in the United States, yet the factors that prompt individuals to adopt healthier habits are not well understood., Methods: This study was undertaken to determine whether individuals who have experienced recent adverse health events are more likely to quit smoking or to lose weight than those without recent events using Health and Retirement Study panel survey data for 20 221 overweight or obese individuals younger than 75 years and 7764 smokers from 1992 to 2000., Results: In multivariate analyses, adults with recent diagnoses of stroke, cancer, lung disease, heart disease, or diabetes mellitus were 3.2 times more likely to quit smoking than were individuals without new diagnoses (P < .001). Among overweight or obese individuals younger than 75 years, those with recent diagnoses of lung disease, heart disease, or diabetes mellitus lost -0.35 U of body mass index (calculated as weight in kilograms divided by height in meters squared) compared with those without these new diagnoses (P < .001). Smokers with multiple new diagnoses were 6 times more likely to quit smoking compared with those with no new diagnoses. The odds of quitting smoking were 5 times greater in individuals with a new diagnosis of heart disease, and body mass index declined by 0.6 U in overweight or obese individuals with a new diagnosis of diabetes mellitus (P < .001)., Conclusions: Across a range of health conditions, new diagnoses can serve as a window of opportunity that prompts older adults to change health habits, in particular, to quit smoking. Quality improvement efforts targeting secondary as well as primary prevention through the health care system are likely well founded.

Engaging consumers to be more active participants in their health and health care is an appealing strategy for reforming the U.S. health care system, but little is known about how to mount and sustain communitywide consumer engagement initiatives. The Robert Wood Johnson Foundation launched a program in 2006 in fourteen communities to align forces around improving quality and efficiency by promoting public reporting and expanding the involvement of consumers in all facets of their care. These multistakeholder organizations provide an early glimpse into the opportunities and challenges that lie ahead as policymakers attempt to integrate consumers more completely in their reform strategies.

The assessment of medical practice is evolving rapidly in the United States. An initial focus on structure and process performance measures assessing the quality of medical care is now being supplemented with efficiency measures to quantify the "value" of healthcare delivery. This statement, building on prior work that articulated standards for publicly reported outcomes measures, identifies preferred attributes for measures used to assess efficiency in the allocation of healthcare resources. The attributes identified in this document combined with the previously published standards are intended to serve as criteria for assessing the suitability of efficiency measures for public reporting. This statement identifies the following attributes to be considered for publicly reported efficiency measures: integration of the quality and cost; valid cost measurement and analysis; minimal incentive to provide poor quality care; and proper attribution of the measure. The attributes described in this statement are relevant to a wide range of efforts to profile the efficiency of various healthcare providers, including hospitals, healthcare systems, managed-care organizations, physicians, group practices, and others that deliver coordinated care.

The assessment of medical practice is evolving rapidly in the United States. An initial focus on structure and process performance measures assessing the quality of medical care is now being supplemented with efficiency measures to quantify the "value" of healthcare delivery. This statement, building on prior work that articulated standards for publicly reported outcomes measures, identifies preferred attributes for measures used to assess efficiency in the allocation of healthcare resources. The attributes identified in this document combined with the previously published standards are intended to serve as criteria for assessing the suitability of efficiency measures for public reporting. This statement identifies the following attributes to be considered for publicly reported efficiency measures: integration of the quality and cost; valid cost measurement and analysis; minimal incentive to provide poor quality care; and proper attribution of the measure. The attributes described in this statement are relevant to a wide range of efforts to profile the efficiency of various healthcare providers, including hospitals, healthcare systems, managed-care organizations, physicians, group practices, and others that deliver coordinated care.

Background: Readmission soon after hospital discharge is an expensive and often preventable event for patients with heart failure. We present a model approved by the National Quality Forum for the purpose of public reporting of hospital-level readmission rates by the Centers for Medicare & Medicaid Services., Methods and Results: We developed a hierarchical logistic regression model to calculate hospital risk-standardized 30-day all-cause readmission rates for patients hospitalized with heart failure. The model was derived with the use of Medicare claims data for a 2004 cohort and validated with the use of claims and medical record data. The unadjusted readmission rate was 23.6%. The final model included 37 variables, had discrimination ranging from 15% observed 30-day readmission rate in the lowest predictive decile to 37% in the upper decile, and had a c statistic of 0.60. The 25th and 75th percentiles of the risk-standardized readmission rates across 4669 hospitals were 23.1% and 24.0%, with 5th and 95th percentiles of 22.2% and 25.1%, respectively. The odds of all-cause readmission for a hospital 1 standard deviation above average was 1.30 times that of a hospital 1 standard deviation below average. State-level adjusted readmission rates developed with the use of the claims model are similar to rates produced for the same cohort with the use of a medical record model (correlation, 0.97; median difference, 0.06 percentage points)., Conclusions: This claims-based model of hospital risk-standardized readmission rates for heart failure patients produces estimates that may serve as surrogates for those derived from a medical record model.

Background: Readmission after heart failure (HF) hospitalization is an increasing focus for physicians and policy makers, but statistical models are needed to assess patient risk and to compare hospital performance. We performed a systematic review to describe models designed to compare hospital rates of readmission or to predict patients' risk of readmission, as well as to identify studies evaluating patient characteristics associated with hospital readmission, all among patients admitted for HF., Methods: We identified relevant studies published between January 1, 1950, and November 19, 2007, by searching MEDLINE, Scopus, PsycINFO, and all 4 Ovid Evidence-Based Medicine Reviews. Eligible English-language publications reported on readmission after HF hospitalization among adult patients. We excluded experimental studies and publications without original data or quantitative outcomes., Results: From 941 potentially relevant articles, 117 met inclusion criteria: none contained models to compare readmission rates among hospitals, 5 (4.3%) presented models to predict patients' risk of readmission, and 112 (95.7%) examined patient characteristics associated with readmission. Studies varied in case identification, used multiple types of data sources, found few patient characteristics consistently associated with readmission, and examined differing outcomes, often either readmission alone or a combined outcome of readmission or death, measured across varying periods (from 14 days to 4 years). Two articles reported model discriminations of patient readmission risk, both of which were modest (C statistic, 0.60 for both)., Conclusions: Our systematic review identified no model designed to compare hospital rates of readmission, while models designed to predict patients' readmission risk used heterogeneous approaches and found substantial inconsistencies regarding which patient characteristics were predictive. Clinically, patient risk stratification is challenging. From a policy perspective, a validated risk-standardized statistical model to accurately profile hospitals using readmission rates is unavailable in the published English-language literature to date.

Background: Veterans Affairs medical centers (VAMCs) provide better preventive and chronic disease care when compared with other health care organizations, although recent health care quality improvement initiatives outside the VAMC sector may have narrowed quality differences., Methods: Using the nationally representative 2000 and 2004 surveys of the Behavior Risk Factor Surveillance System, which included 152,310 community-dwelling insured adults in 2000 and 251,570 in 2004, we compared self-reported use of 17 recommended ambulatory care services for cancer prevention, cardiovascular risk reduction, diabetes mellitus management, and infectious disease prevention among insured adults receiving and not receiving care at VAMCs., Results: A total of 2852 insured adults (1.9%) received care at VAMCs in 2000 and 7155 (2.4%) received care at VAMCs in 2004. Use of 9 of the 17 services was greater in 2004 when compared with 2000 (P < or = .05). In 2000, receiving VAMC care was associated with greater use of 6 of the 17 services; in 2004, receiving VAMC care was associated with greater use of 12 of the 17 services (P < or = .05). In 2004, greater use among these 12 services ranged from 10% greater use of cholesterol screening to 40% greater use of colorectal cancer screening. For 13 of the 17 services, the likelihood of service use among adults receiving VAMC care when compared with adults not receiving VAMC care was not significantly different in 2004 than in 2000. However, this likelihood was significantly greater (for VAMC vs non-VAMC use) in 2004 than in 2000 for breast cancer screening (relative risk [RR], 1.21 [95% confidence interval {CI}, 1.15-1.25] vs 0.80 [95% CI, 0.58-0.98]; P < .001), dilated eye examination among adults with diabetes (RR, 1.12 [95% CI, 1.07-1.15] vs 1.01 [95% CI, 0.88-1.09]; P = .04), and influenza (RR, 1.30 [95% CI, 1.24-1.36] vs 1.06 [95% CI, 0.89-1.21]; P = .006) and pneumococcal (RR, 1.27 [95% CI, 1.23-1.31] vs 1.04 [95% CI, 0.86-1.21]; P = .005) vaccinations., Conclusion: Despite increasing emphasis on quality of care and improved performance throughout the US health care system, adults receiving VAMC care remain more likely to receive recommended ambulatory care.

Background: Use of more than one health care system to obtain care is common among adults receiving care within the Veterans Affairs (VA) medical system. It is not known what effect using care from multiple sources has on the quality of care patients receive., Objectives: To examine whether use of recommended ambulatory care services differs between exclusive and dual VA users., Methods: Cross-sectional analysis of the 2004 Behavior Risk Factor Surveillance System, a nationally-representative survey of community-dwelling adults aged 18 years or older. Our outcome measures were self-reported use of 18 recommended services for cancer prevention, cardiovascular risk reduction, diabetes management, and infectious disease prevention. We used multivariable logistic regression to examine the association between exclusive and dual VA use and use of recommended ambulatory services., Results: There were 3470 exclusive VA users and 4523 dual VA users. Dual users were significantly more likely to be older and white, have higher incomes, have graduated from college, and be insured when compared with exclusive VA users. In unadjusted analyses, dual users received higher rates of recommended services. After adjustment for patient characteristics, use of recommended services was largely similar among exclusive and dual VA users. Exclusive VA users reported 14% greater use of breast cancer screening and 10% greater use of cholesterol monitoring among patients with hypercholesterolemia, and 6% lower use of prostate cancer screening and 7% lower use of influenza vaccination., Conclusions: After adjustment for patient characteristics, exclusive and dual VA users reported similar rates of recommended ambulatory service use.