VA's Primary Care-Mental Health Integration Affects Access Differently for Women and Men Veterans
BACKGROUND:
Growing numbers of women Veterans (estimated to increase from 10% to 14% of all Veterans by 2033) seek VA healthcare. Depression and anxiety disproportionately affect women Veterans compared to male Veterans. Beginning in 2007, VA invested to improve access to mental healthcare through the national Primary Care-Mental Health Integration (PC-MHI) initiative. Through PC-MHI care models, primary care providers, mental health specialists, and/or care managers jointly manage mild-to-moderate psychiatric conditions directly in primary care settings. This retrospective cohort study of 5.4 million Veterans (including 448,455 women), who received care at one of 396 VA primary care clinics between FY2013 and FY2016, set out to answer the following question: Did VA’s national PC-MHI initiative improve access to care equally among men and women Veterans? Investigators estimated VA healthcare use (mental health, primary care, other specialty care, telephone, hospitalizations) and total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-reported gender and clinic PC-MHI penetration.
FINDINGS:
- Mental health integration in primary care was associated with greater use of all outpatient services among men but with lower use of services (except primary care visits) among women. Both men and women had more primary care visits (+22% and +40%, respectively) and total costs over time, but women had 74% fewer hospitalizations (versus +2% in men) related to mental health integration.
- Each percentage point increase in the proportion of Veterans who saw an integrated specialist was associated with 38% fewer mental health visits per year for women, but 39% more visits for men.
- Women Veterans had twice the rates of depression and anxiety and used more mental health and primary care services than men. Also, women Veterans were more likely than men to receive care in hospital-based (vs. community-based) clinics, where average PC-MHI penetration rates are higher and where women-only treatment settings are more commonly located.
IMPLICATIONS:
- Enabling mental healthcare (MH) through PC-MHI has differing impacts on men and women Veterans and differing health system impacts. In men, addressing unmet MH needs in PC-MHI may increase demand for specialty MH, whereas in women PC-MHI appears to offer an alternative to specialty MH care.
LIMITATIONS:
- This study did not distinguish between VA women’s health clinics and general primary care, control for several factors related to care integration (e.g., mental healthcare staffing), or include emergency visits, all of which may affect healthcare use.
- This study did not include healthcare received outside VA.
AUTHOR/FUNDING INFORMATION:
Dr. Leung was funded by an HSR&D Career Development Award, and Dr. Yano is supported by an HSR&D Senior Research Career Scientist Award. Drs. Leung, Hamilton, and Yano are part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP).
Leung LB, Rubenstein LV, Post EP, Trivedi R, Hamilton AB, Yoon J, Jaske E, and Yano EM. Association of Veterans Affairs Primary Care Mental Health Integration with Care Access among Men and Women Veterans. JAMA Network Open. October 20, 2020;3(10):e2020955.
