VA Health Care: How Distance from VA Facilities Affects Veterans' Use of
VA Services (Letter Report, 12/20/95, GAO/HEHS-96-31).

Pursuant to a congressional request, GAO provided information on
veterans' use of Department of Veterans Affairs' (VA) health care
facilities, focusing on: (1) the percentage of veterans living within
certain distances of a VA facility; (2) whether distance affected
veterans' use of VA facilities; and (3) whether veterans receiving VA
disability compensation or pensions are less sensitive to distance from
a VA facility than other veterans.

GAO found that: (1) although most veterans live within 25 miles of a VA
facility, veterans living within 5 miles of a facility are much more
likely to use VA health services; (2) about 11 percent of veterans live
within 5 miles of a VA hospital and 17 percent live within 5 miles of a
VA outpatient clinic; (3) veterans receiving VA compensation or pension
payments are less sensitive to distance from a VA facility than veterans
with nonservice-connected disabilities; (4) veterans with
service-connected disabilities living more than 100 miles from a VA
outpatient clinic are more likely to use VA outpatient services than
veterans living within 5 miles of a VA clinic; and (5) differences in
the use of VA services are affected by factors such as veterans'
eligibility for outpatient care, veterans' ages, and available
resources.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-96-31
     TITLE:  VA Health Care: How Distance from VA Facilities Affects 
             Veterans' Use of VA Services
      DATE:  12/20/95
   SUBJECT:  Health care services
             Health resources utilization
             Veterans hospitals
             Veterans disability compensation
             Veterans pensions
             Demographic data

             
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Cover
================================================================ COVER


Report to the Ranking Minority Member, Subcommittee on Compensation,
Pension, Insurance, and Memorial Affairs, Committee on Veterans'
Affairs, House of Representatives

December 1995

VA HEALTH CARE - HOW DISTANCE FROM
VA FACILITIES AFFECTS VETERANS'
USE OF VA SERVICES

GAO/HEHS-96-31

Distance From VA Facilities

(406088)


Abbreviations
=============================================================== ABBREV

  CHAMPUS - Civilian Health and Medical Program of the Uniformed
     Services
  NSC - nonservice-connected
  SC - service-connected
  VA - Department of Veterans Affairs

Letter
=============================================================== LETTER


B-259617

December 20, 1995

The Honorable Lane Evans
Ranking Minority Member
Subcommittee on Compensation, Pension,
 Insurance, and Memorial Affairs
Committee on Veterans' Affairs
House of Representatives

Dear Mr.  Evans: 

In fiscal year 1994, the Department of Veterans Affairs (VA) provided
medical care to about 2.5 million (9.4 percent) of the nation's 26.5
million veterans.  Although VA operates one of the largest health
care delivery systems in the United States, veterans frequently
indicate that they do not use VA health services because they live
too far from the nearest VA hospital or outpatient clinic. 

This report responds to your request for information relating to the
role of distance in predicting veterans' use of VA health care. 
Specifically, it answers the following questions: 

  What percentage of the veteran population lives within selected
     distances of a VA hospital and outpatient clinic offering basic
     acute medical and surgical care? 

  How does the distance a veteran lives from a VA hospital or
     outpatient clinic affect the likelihood that he or she will use
     VA for acute medical and surgical care? 

  Is the number of services per veteran user higher for veterans
     living close to a VA hospital or clinic? 

  Is use of VA health care facilities by veterans receiving VA
     compensation for service-connected disabilities or VA low-income
     pensions more or less sensitive to how far they live from a VA
     facility than use by other veterans? 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :1

To develop this information, we used data from the 1990 Census and
VA's patient treatment file, compensation and pension file,\1 and
outpatient file.  We measured distances between veterans' homes and
the nearest VA hospital and outpatient clinic based on the zip codes
of VA facilities and veterans' residences.  We focused our work on
acute medical and surgical care.\2 Accordingly, we excluded from our
universe of hospitals 40 VA hospitals that (1) primarily provide
long-term psychiatric care and (2) do not provide surgical care.  A
total of 131 of VA's 171 hospitals were included in our universe. 
However, the patients discharged from all 171 hospitals were included
in our analyses except as noted below. 

We then made several adjustments to data in the patient treatment
file.  Because of our focus on acute medical and surgical care, we
excluded patients discharged from (1) psychiatric bed sections and
(2) nonacute bed sections, including patients discharged from nursing
home and intermediate care units; inpatient substance abuse
treatment, post-traumatic stress disorder, and respite care programs;
and halfway houses and hospices. 

Similarly, we excluded from our analyses those VA outpatient clinics
(and the associated outpatient visits) that (1) primarily provide
psychiatric counseling or (2) do not provide a broad range of acute
medical and surgical care.  We also excluded visits to community
providers reimbursed by VA on a fee basis.  Veterans who used acute
medical, surgical, or psychiatric services as well as nonacute VA
programs were included in our analyses as users, but their nonacute
services were excluded from the analyses of the number of outpatient
visits.  Our universe included 269 VA outpatient clinics that provide
a wide range of acute medical and surgical care.\3 (See app.  I for a
detailed description of our methodology.)

We conducted our work between May 1994 and August 1995 in accordance
with generally accepted government auditing standards. 


--------------------
\1 Information in VA's compensation and pension file was as of March
1993.  Information in the patient treatment file and outpatient file
was for fiscal year 1993. 

\2 Distance may also be an important factor in veterans' decisions
regarding use of VA psychiatric care.  We excluded psychiatric care
from this analysis, however, because many psychiatric hospitals offer
a limited range of acute medical and surgical care.  Their inclusion
in the universe of facilities would, therefore, give a misleading
picture of the availability of acute medical and surgical hospital
care. 

\3 A total of 256 zip codes were involved; 13 pairs of outpatient
clinics had the same zip code. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :2

Living within 5 miles of a VA hospital or outpatient clinic
significantly increases the likelihood that a veteran will use VA
health care services.  Although most veterans live within 25 miles of
a VA hospital and outpatient clinic, use of VA facilities, in terms
of both likelihood of VA use and the frequency of use, declines
significantly among veterans living more than 5 miles from a VA
facility.  Only about 11 percent of veterans live within 5 miles of a
VA hospital providing acute medical and surgical care and 17 percent
within 5 miles of a VA outpatient clinic. 

Use of VA health care services does not decline with distance as
rapidly among veterans receiving VA compensation or pension payments. 
Even those veterans with service-connected disabilities who live more
than 100 miles from a VA outpatient clinic are more likely to use VA
outpatient services than are higher income veterans with
nonservice-connected disabilities who live within 5 miles of a VA
outpatient clinic.\4 A number of factors, including broader
eligibility and entitlement to outpatient care for service-connected
and low-income veterans, veterans' ages, and differences in available
resources, could also contribute to the differences in use of VA
services. 


--------------------
\4 This report uses the shorthand terms "service-connected veterans"
and "nonservice-connected veterans" to refer to these two groups.  As
used in this report, "higher income" refers to nonservice-connected
veterans not receiving a VA pension.  This group includes an unknown
number of veterans with incomes below the level that would qualify
them for a pension but who are not receiving a VA pension.  Data were
not readily available to permit a more precise breakout of veterans'
incomes. 


   BACKGROUND
------------------------------------------------------------ Letter :3

In fiscal year 1993, VA operated 171 hospitals, 128 nursing homes, 38
domiciliaries, and 353 outpatient clinics.  VA facilities vary widely
in the types and complexities of the services provided.  For example,
some of the hospitals are large facilities providing a wide range of
acute medical, surgical, and psychiatric care.  VA also operates
smaller rural hospitals providing more limited acute medical and
surgical care.  Still others provide primarily long-term psychiatric
care and do not perform surgery. 

Similarly, there is considerable variability in the services
available from VA outpatient clinics.  In addition to the outpatient
clinics located within medical centers, some VA medical centers
operate satellite clinics in other locations.  VA also operates
several large, independent outpatient clinics and numerous smaller,
community-based, rural outreach, and mobile clinics providing a
narrower range of services. 


   MOST VETERANS LIVE WITHIN 25
   MILES OF A VA ACUTE CARE
   FACILITY
------------------------------------------------------------ Letter :4

About 89 percent of veterans live more than 5 miles from a VA
hospital providing acute medical and surgical care, but about 50
percent live within 25 miles.  Similarly, approximately 83 percent of
veterans live more than 5 miles from a VA outpatient clinic, but
about two-thirds live within 25 miles.  (See fig.  1 and tables II.1
and II.2.)

   Figure 1:  Percentage of the
   Veteran Population Living
   Within Selected Distances of VA
   Acute Care Facilities

   (See figure in printed
   edition.)

Source:  Based on 1990 Census data. 


   VETERANS LIVING WITHIN 5 MILES
   OF A VA FACILITY MOST LIKELY TO
   USE VA
------------------------------------------------------------ Letter :5

Veterans who live close to a VA facility are more likely to use VA
hospital and outpatient services, but users of outpatient services
appear to be more sensitive to distance.  Although only 11 percent of
veterans live within 5 miles of a VA hospital, such veterans account
for 22 percent of VA acute medical and surgical patients.  Similarly,
the 17 percent of veterans living within 5 miles of a VA outpatient
clinic accounted for 26 percent of outpatient clinic users.  (See
fig.  2 and tables II.1 and II.2.)

   Figure 2:  Percentage of
   Veterans Using VA Health Care
   Services, by Distance From VA
   Acute Care Facilities

   (See figure in printed
   edition.)

Source:  Based on VA's fiscal year 1993 patient treatment and
outpatient files. 

In other words, for every 1,000 veterans living within 5 miles of a
VA hospital, there were 34 who used a VA hospital for acute medical
or surgical care in fiscal year 1993; at greater distances from a VA
hospital, only about 15 used VA hospital care.  Similarly, the number
of outpatient users per 1,000 veterans was significantly higher for
veterans living within 5 miles of a VA outpatient clinic--131 per
1,000 veterans--than at greater distances--fewer than 80 per 1,000
veterans.  (See fig.  3 and tables II.1
and II.2.)

   Figure 3:  Users per 1,000
   Veterans, by Distance From VA
   Acute Care Facilities

   (See figure in printed
   edition.)


   VOLUME OF SERVICES USED IS ALSO
   SENSITIVE TO DISTANCE
------------------------------------------------------------ Letter :6

Distance also appears to play a role in the volume of services used. 
Generally, the number of outpatient visits per user decreased as
veterans' distances from VA clinics increased.  For example, the 26
percent of VA users living within 5 miles of a VA outpatient clinic
accounted for 35 percent of outpatient visits.  VA officials pointed
out that visits may not be the best measure of the volume of services
veterans use; veterans traveling longer distances to a VA clinic may
make fewer visits but have more clinic stops on those visits than
veterans living closer to the VA facility.  Distance had little
impact on the number of inpatient episodes of care VA users obtained
from VA hospitals.  (See fig.  4 and tables II.3
and II.4.)

   Figure 4:  Services per Veteran
   User, by Distance From VA Acute
   Care Facility

   (See figure in printed
   edition.)


   SERVICE-CONNECTED AND
   LOW-INCOME VETERANS LESS
   SENSITIVE TO DISTANCE
------------------------------------------------------------ Letter :7

Veterans receiving compensation for service-connected disabilities or
VA low-income pensions for nonservice-connected disabilities appear
less sensitive to distance than other veterans.  Veterans receiving
VA compensation or pension payments are significantly more likely to
use VA health care services than other veterans with no
service-connected disabilities regardless of how far they live from a
VA hospital or outpatient clinic.  And, their use of VA health care
services does not decline as quickly at increasing distances from VA
facilities.  For example, use of VA outpatient clinics by veterans
with service-connected disabilities rated at 50 percent or higher
declined by about 10 percent, from 704 users per 1,000 veterans
living within 5 miles of a VA outpatient clinic to 630 users per
1,000 veterans living between 6 and 25 miles from a clinic.  By
contrast, use by nonservice-connected veterans not receiving VA
pensions declined by over 50 percent, from 91 users per 1,000
veterans living within 5 miles of a VA outpatient clinic to 45 users
per 1,000 veterans living between 6 and 25 miles from a clinic.  (See
fig.  5 and tables II.13 through II.14.)

   Figure 5:  VA Outpatient Clinic
   Users per 1,000 Veterans, by
   Distance and Service-Connected
   Status

   (See figure in printed
   edition.)

Notes:  SC is service-connected veteran; NSC is nonservice-connected
veteran. 

Figure is based on fiscal year 1993 data. 

In addition to being more likely to use VA hospitals and outpatient
clinics, veterans receiving (1) compensation for service-connected
disabilities rated at 50 percent or higher or (2)
nonservice-connected pensions use a higher volume of services than
higher income nonservice-connected veterans.  Veterans receiving
compensation for service-connected disabilities rated at less than 50
percent are more likely to use VA services than higher income
nonservice-connected veterans, but both types of users have roughly
comparable numbers of discharges and outpatient visits.  (See fig.  6
and tables II.11 and II.12.)

   Figure 6:  VA Outpatient Visits
   per Veteran User, by Distance
   and Service-Connected Status

   (See figure in printed
   edition.)

Notes:  SC is service-connected veteran; NSC is nonservice-connected
veteran.

Figure is based on fiscal year 1993 data. 

Several factors other than distance could help explain the
differences.  For example, service-connected veterans, particularly
those with disabilities rated at 50 percent or more, have broader
eligibility for VA outpatient services than do nonservice-connected
veterans.  Similarly, VA pension recipients probably have fewer
health care options than higher income veterans.  For example, they
are unlikely to have employer-provided health insurance and may be
unable to afford the out-of-pocket costs they would incur through use
of their Medicare benefits. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :8

We obtained comments on a draft of this report from the Deputy Under
Secretary for Health and other VA officials.  The Deputy Under
Secretary said accessibility is an important aspect of quality health
care and making VA health care services more accessible has long been
a goal of VA.  He said, however, that efforts to open additional
outpatient "access point" clinics have been delayed until VA can
communicate the details of its plans to the Congress.  VA's recent
reorganization into 22 service networks will provide veterans better
access to care, the Deputy Under Secretary said. 

VA officials expressed the following concerns about our methodology: 

  Distance may not be as important as travel time in veterans'
     decisions about whether to use VA health care facilities.  In
     their view, distance does not account for and is not
     representative of geographic barriers, road conditions,
     congestion, and other factors that might influence veterans' use
     of VA medical centers.  We agree and previously identified this
     limitation in our scope and methodology (see p.  18).  We are
     not aware of any database that would have enabled us to measure
     veterans' travel times from VA medical centers. 

  Excluding psychiatric and long-term care facilities distorted our
     analyses.  About 50 percent of VA medical and surgical patients
     have some lifetime psychiatric diagnoses or recurring symptoms. 
     With limited availability and funding for psychiatric care in
     the private sector, veterans may be more willing to travel to VA
     facilities for these services.  As a result, access to VA
     psychiatric care affects veterans' willingness to travel to VA. 
     Also, VA facilities that offer medical and surgical care as well
     as psychiatric services are large and provide a significant
     portion of care rendered by VA. 

We agree that veterans seeking VA psychiatric services may be less
sensitive to distance than those seeking medical or surgical care and
that the role of distance in predicting use of VA psychiatric care
may warrant further study.  However, including facilities that do not
provide a wide range of medical and surgical services in an
evaluation of the role of distance in predicting the use of VA
medical and surgical care would distort the results of that analysis. 
Moreover, veterans who used both medical or surgical services and
psychiatric services in fiscal year 1993 were included in our
analyses regardless of whether they were treated in the excluded
facilities. 

  Visits may not be an appropriate indicator of volume.  Patients who
     travel greater distances to VA combine many clinic stops into
     one visit, thereby increasing the intensity of the care for each
     visit.  We agree and recognized this limitation in our report
     (see p.  6).  Although VA's point appears logical, we are not
     aware of any studies that show the extent to which veterans
     living greater distances from VA facilities obtain more services
     per visit than veterans living closer to VA facilities. 

  Our percentage distributions by distance compare the user
     population with the entire veteran population, but the report
     does not contain the same types of analyses for nonusers.  Data
     on nonusers can easily be derived from the tables in appendix
     II. 


---------------------------------------------------------- Letter :8.1

We are sending copies of this report to the Chairmen and Ranking
Minority Members of the Senate and House Committees on Veterans'
Affairs and the Secretary of Veterans Affairs.  Copies will be made
available to others upon request. 

This work was performed under the direction of James R.  Linz,
Assistant Director, who may be reached at (202) 512-7110 if you or
your staff have questions concerning this report.  Other major
contributors include Linda Diggs, Sibyl Tilson, and Joan Vogel. 

Sincerely yours,

David P.  Baine
Director, Health Care Delivery
 and Quality Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

This appendix provides additional details on development of the
universes of VA hospitals, outpatient clinics, and users on which our
analyses were based and the methodologies used in our analyses. 


   DEVELOPING A UNIVERSE OF VA
   HOSPITALS
--------------------------------------------------------- Appendix I:1

In fiscal year 1993, VA operated 171 hospitals, some of which
provided only limited acute medical and surgical care services.  To
develop a universe of VA hospitals providing acute medical and
surgical care for our analyses, we excluded 40 hospitals that (1)
primarily provide long-term psychiatric care, (2) do not provide
surgical care, or (3) are located outside the 48 contiguous states
(that is, are located in Alaska and Puerto Rico).  Hence, 131
hospitals were included in our universe of VA acute medical and
surgical hospitals.  However, the patients discharged from all 171
hospitals were included in our analyses except as noted below. 


   DEVELOPING A UNIVERSE OF
   MEDICAL AND SURGICAL HOSPITAL
   USERS
--------------------------------------------------------- Appendix I:2

From VA's fiscal year 1993 patient treatment file, we developed a
universe of veteran users of VA acute medical and surgical hospital
care by (1) excluding all discharges (6,219) of nonveterans (5,159)
who used VA inpatient services; (2) deleting discharges from state
veterans' homes and other non-VA facilities; (3) deleting discharges
from VA nursing homes and domiciliaries; (4) deleting discharges from
psychiatric bed sections; and (5) deleting discharges from nonacute
bed sections, including inpatient substance abuse treatment programs,
post-traumatic stress disorder programs, respite care programs,
halfway houses, and hospices.  Veterans who used both acute medical
or surgical services and nonacute VA programs were included in our
analyses as users, but their nonacute episodes of care were excluded
from our analyses of the numbers of veterans' inpatient stays.  The
inpatient analyses included 462,809 veterans and about 777,190
discharges (see table I.1). 



                               Table I.1
                
                  Summary of Data Exclusions From VA's
                        Inpatient Treatment File

Type of               Original                            Adjusted
adjustment            universe         Exclusions         universe
----------------  ----------------  ----------------  ----------------
Inpatient             910,867           133,677           777,190
 discharges
Hospitals               171                40               131
Veteran users         479,512            16,703           462,809
----------------------------------------------------------------------

   DEVELOPING OUTPATIENT UNIVERSES
--------------------------------------------------------- Appendix I:3

In fiscal year 1993, VA operated 353 outpatient clinics, including
many providing primarily mental health services or only a narrow
range of medical services.  To develop a universe of VA outpatient
clinics offering a broad range of acute medical and surgical
services, we excluded (1) mobile clinics and other clinics offering
primarily eligibility screening, substance abuse outreach, mental
health, or psychiatric services; and (2) clinics located outside the
48 contiguous states (that is, clinics in Alaska, Hawaii, and Puerto
Rico).  A total of 84 of VA's 353 outpatient clinics were excluded. 
From VA's fiscal year 1993 outpatient file, we developed a universe
of veteran users by excluding (1) all visits to the 84 outpatient
clinics removed from our universe; (2) all visits (995,323) to VA
clinics by nonveterans (328,418), such as beneficiaries in the
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS) or VA employees; and (3) outpatient visits to community
providers who were reimbursed by VA on a fee basis.  After
adjustments, our analyses included 269 outpatient clinics,
approximately 2.3 million outpatient users, and about 21.6 million
visits.\5 (See table I.2.)



                               Table I.2
                
                  Summary of Data Exclusions From VA's
                         Outpatient Clinic File

Type of               Original                            Adjusted
adjustment            universe         Exclusions         universe
----------------  ----------------  ----------------  ----------------
Outpatient           23,329,333        1,681,898         21,647,435
 visits
Clinics                 353                84               269
Veteran users        2,626,228          352,221          2,274,007
----------------------------------------------------------------------

--------------------
\5 A total of 256 zip codes were involved; 13 pairs of outpatient
clinics had the same zip code. 


   DETERMINING HOW MANY VETERANS
   LIVE WITHIN SELECTED DISTANCES
   OF VA FACILITIES
--------------------------------------------------------- Appendix I:4

To determine how many veterans live within selected distances of VA
hospitals and outpatient clinics offering a broad range of acute
medical and surgical care, we

  measured the straight-line distance between every residential zip
     code in the 48 contiguous states and the nearest VA hospital and
     outpatient clinic included in our universes;

  determined how many veterans lived within each zip code using 1990
     Census data; and

  compiled the data on number of veterans living in each zip code in
     5-mile increments from the closest VA hospital and outpatient
     clinic. 


   DETERMINING HOW DISTANCE
   AFFECTS LIKELIHOOD OF VA USE
--------------------------------------------------------- Appendix I:5

To determine the effect of distance on the likelihood that veterans
will use VA hospital and outpatient services, we

  determined the number of VA users in each zip code in the 48
     contiguous states (using data from the fiscal year 1993 patient
     treatment file and outpatient file) for both hospital and
     outpatient care;

  calculated the percentage of the user population living within
     5-mile increments of the closest VA inpatient hospital and
     outpatient clinic; and

  compared the proportion of users with the proportion of veterans
     living within selected distances of VA facilities. 


   DETERMINING THE EFFECT OF
   DISTANCE ON VOLUME OF SERVICES
--------------------------------------------------------- Appendix I:6

To determine whether distance affected the volume of services VA
users obtain from VA, we

  calculated the number of hospital stays and outpatient visits for
     each VA user in our universe;

  calculated the percentage of the visits or discharges attributed to
     users living within 5-mile increments of the closest VA
     inpatient hospital or outpatient clinic; and

  compared the proportion of visits or discharges with the proportion
     of users living within selected distances of VA facilities. 


   DETERMINING WHETHER
   SERVICE-CONNECTED VETERANS AND
   PENSION RECIPIENTS ARE MORE
   SENSITIVE TO DISTANCE
--------------------------------------------------------- Appendix I:7

To determine whether veterans with service-connected disabilities or
receiving VA pensions are more or less sensitive to distance, we

  established a universe of service-connected veterans and veterans
     receiving VA pensions using VA's compensation and pension
     file;\6

  conducted the analyses previously described for veterans receiving
     VA compensation or pension payments; and

  compared the results with those of nonservice-connected veterans
     not receiving pensions. 

Our analyses have several limitations.  First, the use of
straight-line distance between zip codes does not account for
differences in travel time due to road conditions, congestion, or
structures such as bridges or tunnels, or differences in travel
distances caused by geographic barriers such as rivers and mountains. 
Second, veterans do not always use the VA facilities closest to their
homes or may use multiple facilities or move during the year.  Third,
the accuracy of the zip code data in VA's patient treatment file and
outpatient file was not verified. 

We conducted our work between May 1994 and August 1995 in accordance
with generally accepted government auditing standards. 


--------------------
\6 Information in VA's compensation and pension file was as of March
1993. 


VETERAN POPULATION AND VA USERS BY
DISTANCE FROM VA FACILITIES
========================================================== Appendix II

This appendix contains tables showing the distribution of the veteran
population and VA users by distance from VA hospitals and outpatient
clinics providing acute medical and surgical care.  The first 4
tables provide information on the overall veteran population; the
remaining 10 tables provide a more detailed breakout of the veteran
population by service-connected status.  The tables are based on our
analyses of VA's fiscal year 1993 patient treatment file, outpatient
file, and compensation and pension file along with 1990 Census data. 



                               Table II.1
                
                 Distribution of Veterans and Users per
                 1,000 Veterans by Distance to VA Acute
                   Care Hospitals (Fiscal Year 1993)


                                                                 Users
                                                                   per
                                                                 1,000
                                        Percen          Percen  vetera
Distance (miles)                Number    tage  Number    tage      ns
------------------------------  ------  ------  ------  ------  ------
0-5                             3,004,      11  101,72      22   33.86
                                   187               2
6-25                            10,441      39  159,61      34   15.29
                                  ,653               2
26-100                          11,861      44  178,95      39   15.09
                                  ,595               6
Over 100                        1,641,       6  22,519       5   13.72
                                   587
======================================================================
Total                           26,949     100  462,80     100   17.17
                                  ,022               9
----------------------------------------------------------------------


                               Table II.2
                
                 Distribution of Veterans and Users per
                    1,000 Veterans by Distance to VA
                Outpatient Clinics Providing Acute Care
                           (Fiscal Year 1993)


                                                                 Users
                                                                   per
                                                                 1,000
                                        Percen          Percen  vetera
Distance (miles)                Number    tage  Number    tage      ns
------------------------------  ------  ------  ------  ------  ------
0-5                             4,488,      17  589,38      26  131.30
                                   856               3
6-25                            13,275      49  959,78      42   72.30
                                  ,406               8
26-100                          8,830,      33  697,43      31   78.98
                                   577               0
Over 100                        354,18       1  27,406       1   77.38
                                     3
======================================================================
Total                           26,949     100  2,274,     100   84.38
                                  ,022             007
----------------------------------------------------------------------


                               Table II.3
                
                  Number of VA Hospital Discharges per
                Veteran User by Distance From Nearest VA
                 Hospital Providing Acute Care (Fiscal
                               Year 1993)

                                            Hospital    Discharges per
Distance (miles)      Hospital users      discharges      veteran user
--------------------  --------------  --------------  ----------------
0-5                          101,722         176,058              1.73
6-25                         159,612         270,814              1.70
26-100                       178,956         294,666              1.65
Over 100                      22,519          35,652              1.58
======================================================================
Total                        462,809         777,190              1.68
----------------------------------------------------------------------


                         Table II.4
          
             Number of VA Outpatient Visits per
          Veteran User by Distance From Nearest VA
           Outpatient Clinic Providing Acute Care
                     (Fiscal Year 1993)

                                    Outpatie
                          Outpatie        nt    Visits per
Distance (miles)          nt users    visits  veteran user
------------------------  --------  --------  ------------
0-5                        589,383  7,545,73         12.80
                                           7
6-25                       959,788  9,346,47          9.74
                                           1
26-100                     697,430  4,624,82          6.63
                                           3
Over 100                    27,406   130,404          4.76
==========================================================
Total                     2,274,00  21,647,4          9.52
                                 7        35
----------------------------------------------------------


                                    Table II.5
                     
                     Distribution of Veterans by Distance to
                        Nearest VA Acute Care Hospital by
                         Service-Connected Status (1990)



                          Percen          Percen          Percen          Percen
Distance (miles)  Number    tage  Number    tage  Number    tage  Number    tage
----------------  ------  ------  ------  ------  ------  ------  ------  ------
0-5               55,651      13  201,42      12  71,341      16  2,675,      11
                                       6                             769
6-25              150,06      34  631,55      38  112,05      25  9,547,      39
                       9               0               8             976
26-100            199,78      46  726,29      43  236,70      52  10,698      44
                       1               8               2            ,814
Over 100          32,231       7  113,33       7  33,506       7  1,462,       6
                                       1                             519
================================================================================
Total             437,73     100  1,672,     100  453,60     100  24,385     100
                       2             605               7            ,078
--------------------------------------------------------------------------------


                                    Table II.6
                     
                     Distribution of Veterans by Distance to
                      Nearest VA Outpatient Clinic Providing
                      Acute Care by Service-Connected Status
                                      (1990)



                          Percen          Percen          Percen          Percen
Distance (miles)  Number    tage  Number    tage  Number    tage  Number    tage
----------------  ------  ------  ------  ------  ------  ------  ------  ------
0-5               83,981      19  304,43      18  100,67      22  3,999,      16
                                       9               3             763
6-25              194,86      45  811,85      49  142,68      31  12,126      50
                       0               5               5            ,006
26-100            152,95      35  535,99      32  202,05      45  7,939,      33
                       8               1               7             571
Over 100           5,933       1  20,320       1   8,192       2  319,73       1
                                                                       8
================================================================================
Total             437,73     100  1,672,     100  453,60     100  24,385     100
                       2             605               7            ,078
--------------------------------------------------------------------------------


                                    Table II.7
                     
                     Distribution of Veterans Using VA Acute
                     Care Hospitals by Distance and Service-
                       Connected Status (Fiscal Year 1993)



                          Percen          Percen          Percen          Percen
Distance (miles)  Number    tage  Number    tage  Number    tage  Number    tage
----------------  ------  ------  ------  ------  ------  ------  ------  ------
0-5               11,596      18  14,026      20  16,435      23  59,665      24
6-25              23,340      35  25,446      36  20,927      29  89,899      35
26-100            27,270      41  27,547      39  31,672      43  92,467      36
Over 100           3,571       5   3,694       5   3,822       5  11,432       5
================================================================================
Total             65,777     100  70,713     100  72,856     100  253,46     100
                                                                       3
--------------------------------------------------------------------------------
Note:  Percentages may not add to 100 because of rounding. 



                                    Table II.8
                     
                       Distribution of Veterans Who Used VA
                     Outpatient Clinics Providing Acute Care
                     by Distance and Service-Connected Status
                                (Fiscal Year 1993)



                          Percen          Percen          Percen          Percen
Distance (miles)  Number    tage  Number    tage  Number    tage  Number    tage
----------------  ------  ------  ------  ------  ------  ------  ------  ------
0-5               59,082      21  109,70      23  57,779      27  362,81      28
                                       6                               6
6-25              122,71      45  221,23      46  70,102      33  545,74      42
                       3               3                               0
26-100            90,110      33  145,36      30  83,075      39  378,88      29
                                       3                               2
Over 100           3,072       1   5,164       1   3,176       1  15,994       1
================================================================================
Total             274,97     100  481,46     100  214,13     100  1,303,     100
                       7               6               2             432
--------------------------------------------------------------------------------


                                    Table II.9
                     
                        Acute Care Hospital Discharges by
                      Distance and Service-Connected Status
                                (Fiscal Year 1993)



                          Percen          Percen          Percen          Percen
Distance (miles)  Number    tage  Number    tage  Number    tage  Number    tage
----------------  ------  ------  ------  ------  ------  ------  ------  ------
0-5               22,272      19  23,748      21  31,431      24  98,607      24
6-25              42,847      36  41,504      36  39,601      30  146,86      36
                                                                       2
26-100            47,262      40  43,249      38  55,086      42  149,06      36
                                                                       9
Over 100           5,678       5   5,447       5   6,434       5  18,093       4
================================================================================
Total             118,05     100  113,94     100  132,55     100  412,63     100
                       9               8               2               1
--------------------------------------------------------------------------------
Note:  Percentages may add to more than 100 because of rounding. 



                                   Table II.10
                     
                         Visits to VA Outpatient Clinics
                       Providing Acute Care by Distance and
                      Service-Connected Status (Fiscal Year
                                      1993)



                          Percen          Percen          Percen          Percen
Distance (miles)  Number    tage  Number    tage  Number    tage  Number    tage
----------------  ------  ------  ------  ------  ------  ------  ------  ------
0-5               1,199,      29  1,248,      30  959,43      39  4,138,      38
                     642             138               1             526
6-25              1,966,      48  1,927,      47  878,93      35  4,573,      42
                     771             195               1             574
26-100            897,25      22  920,70      22  633,55      25  2,173,      20
                       3               4               1             315
Over 100          21,023       1  24,480       1  17,954       1  66,947       1
================================================================================
Total             4,084,     100  4,120,     100  2,489,     100  10,952     100
                     689             517             867            ,362
--------------------------------------------------------------------------------
Note:  Percentages may add to more than 100 because of rounding. 



                        Table II.11
          
             Acute Care Hospital Discharges per
           Veteran User by Distance and Service-
            Connected Status (Fiscal Year 1993)


                         50-
                     percent      Less
                    disabled  than 50-  Receivin
                          or   percent      g VA
Distance (miles)     greater  disabled   pension     Other
------------------  --------  --------  --------  --------
0-5                     1.92      1.69      1.91      1.65
6-25                    1.84      1.63      1.89      1.63
26-100                  1.73      1.57      1.74      1.61
Over 100                1.59      1.47      1.68      1.58
==========================================================
Total                   1.79      1.61      1.82      1.63
----------------------------------------------------------


                        Table II.12
          
          VA Outpatient Visits per Veteran User by
           Distance and Service-Connected Status
                     (Fiscal Year 1993)


                         50-
                     percent      Less
                    disabled  than 50-  Receivin
                          or   percent      g VA
Distance (miles)     greater  disabled   pension     Other
------------------  --------  --------  --------  --------
0-5                    20.30     11.38     16.61     11.41
6-25                   16.03      8.71     12.54      8.38
26-100                  9.96      6.33      7.63      5.74
Over 100                6.84      4.74      5.65      4.19
==========================================================
Total                  14.85      8.56     11.63      8.40
----------------------------------------------------------


                        Table II.13
          
            Users of VA Acute Hospital Care per
              1,000 Veterans by Distance to VA
             Inpatient Facilities and Service-
            Connected Status (Fiscal Year 1993)


                         50-
                     percent      Less
                    disabled  than 50-  Receivin
                          or   percent      g VA
Distance (miles)     greater  disabled   pension     Other
------------------  --------  --------  --------  --------
0-5                   208.37     69.63    230.37     22.30
6-25                  155.53     40.29    186.75      9.42
26-100                136.50     37.93    133.81      8.64
Over 100              110.79     32.59    114.07      7.82
==========================================================
Total                 150.27     42.28    160.61     10.39
----------------------------------------------------------


                        Table II.14
          
          Users of VA Outpatient Clinics per 1,000
           Veterans by Distance to VA Outpatient
            Clinics and Service-Connected Status
                     (Fiscal Year 1993)


                         50-
                     percent      Less
                    disabled  than 50-  Receivin
                          or   percent      g VA
Distance (miles)     greater  disabled   pension     Other
------------------  --------  --------  --------  --------
0-5                   703.52    360.35    573.93     90.71
6-25                  629.75    272.50    491.31     45.01
26-100                589.12    271.20    411.15     47.72
Over 100              517.78    254.13    387.70     50.02
==========================================================
Total                 628.19    287.85    472.07     53.45
----------------------------------------------------------

*** End of document. ***