Association Of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men And Women Veterans

Importance Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. Objective To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. Design, Setting, and Participants This cohort study included 5377093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. Exposures Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. Main Outcomes and Measures Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. Results This study examined 5377093 veterans (448455 [8.3%] women; 3744140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: beta [SE], 2.23 [0.10]; women: beta [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). Conclusions and Relevance While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.This cohort study of Veterans Health Administration (VA) health care records examines gender differences in care usage since the national integration of mental health services into primary care for veterans.Question Did the Veterans Health Administration (VA)'s national integration of mental health services into primary care beginning in 2007 improve access to care equally among men and women veterans? Findings In this cohort study of 5.4 million veterans (including 448455 women) who received primary care between 2013 and 2016 at VA clinics that provided integrated mental health services, mental health integration was associated with increased use of all outpatient services among men but with decreased use of services (except primary care visits) among women. Meaning Differences in health care utilization by gender highlight the importance of anticipating policy effects and tailoring services for health system patients in the numerical minority.