Differences Between VHA-Delivered and VHA-Purchased Behavioral Health Care in Service and Patient Characteristics

Abstract

Objective:

Federal legislation has expanded Veterans Health Administration (VA) enrollees’ access to VA-purchased “community care.” This study examined differences in the amount and type of behavioral health care delivered in VA and purchased in the community, as well as patient characteristics and area supply/demand factors.

Methods:

This is a retrospective cross-sectional study of 204,094 VA enrollees with 448,648 inpatient behavioral health stays and 3,467,010 VA enrollees with 55,043,607 outpatient behavioral health visits from fiscal years 2016–2019. Standardized mean differences (SMD) were calculated for patient and provider characteristics at the outpatient-visit level for VA and community care. Linear probability models assessed the association between severity of behavioral health condition and where Veterans received care.

Results:

Twenty percent of inpatient stays were purchased through community care, and Veterans with severe behavioral health conditions were more likely to receive inpatient care in VA. In the outpatient setting, community care comprised 3% of behavioral health care, with increasing use over time. Veterans receiving outpatient community care were more likely to see clinicians with fewer years of training (SMD=1.06).

Conclusions:

With a large portion of inpatient behavioral health care occurring in the community as well as increased use of outpatient behavioral health care with less highly-trained community providers, coordination between VA and the community is essential to provide appropriate inpatient follow-up care and facilitate outpatient needs. This is especially critical given VA’s expertise in providing behavioral health care to Veterans and its legislative responsibility to assure integrated care.

INTRODUCTION

In response to access concerns, the Veterans Health Administration (VA) now purchases a considerable amount of care in the community (“community care”). Since implementation of the Choice Act of 2014 (Public Law No. 113–146) and MISSION Act of 2018 (Public Law No. 115–182), over 31% of 8.92 million VA enrollees have received community care referrals.(1) Implications of this transition are unclear for patients with behavioral health needs, who represent over 25% of Veterans receiving VA primary care.(2) Historically these Veterans have relied on VA for behavioral health care, including treatment for psychiatric and substance use disorders.(3–7) Not only are VA providers trained in evidence-based therapies for behavioral health, but they are also trained in military cultural competence, which is often lacking among community providers.(8–11)

Demand for behavioral health care is outpacing supply. For VA to strategically manage its make vs. buy decisions (i.e., provide more services in-house or purchase community care) in the future, it is important to understand current behavioral health utilization patterns in VA and community care, and the relative strengths of each setting in meeting Veterans’ needs. In this study, we hypothesized that, given VA’s expertise in behavioral health care, 1) only a small fraction of Veterans would utilize outpatient behavioral health services in the community, but that a larger portion would utilize inpatient services given the need to address acute behavioral health concerns quickly and close to home; and 2) treatment for more serious (high-risk, high-cost) behavioral health conditions(12) would more likely occur in VA than in the community. Additionally, we anticipated that 3) behavioral health care providers seen in VA outpatient visits would be more highly trained than those seen in community outpatient visits, given VA’s longstanding behavioral health experience and expertise. Understanding the types and characteristics of behavioral health care provided by VA and community care offers an opportunity to help Veterans receive appropriate, high-quality behavioral health care.

METHODS

Study Design.

We conducted a retrospective cross-sectional study from federal fiscal years (FYs) 2016–2019 examining VA-delivered versus VA-purchased behavioral health care. This study was administratively reviewed by the University of X Institutional Review Board and VA Y Health Care System and deemed exempt from human subjects review as a quality improvement initiative. This study adheres to Strengthening the Report of Observational Studies in Epidemiology guidelines for cross-sectional studies.

Data Sources.

We obtained administrative data for VA-delivered care from VA’s Corporate Data Warehouse (CDW) and claims data for community care from CDW’s Performance Integrity Tool, Fee, and Fee Basis Claims System. We created separate inpatient and outpatient datasets because they are distinct care types and inpatient stays occur infrequently compared to outpatient visits. Drive distance to VA primary care (for outpatient analyses) and VA secondary care (for inpatient analyses) came from the VA Planning Systems Support Group. We included county characteristics from the Health Resources and Services Administration’s Area Health Resources File.

Measures

Outcome variables.

The main outcome was whether behavioral health care was provided in VA or the community.

Inpatient behavioral health stays.

VA’s Office of Mental Health and Suicide Prevention provided 616 International Classification of Diseases, Tenth Revision (ICD-10) codes grouped by behavioral health condition type (online supplement): serious mental illness, substance use disorder (SUD), post-traumatic stress disorder (PTSD), personality disorders, mood disorders, anxiety disorders, and other behavioral health disorders. We identified inpatient behavioral health care using the principal diagnosis on VA inpatient stays and community care institutional claims, along with type of bill codes signifying inpatient care (11x, 41x, 42x, and 44x paired with Revenue Codes <250).

Outpatient behavioral health use.

We identified 394 Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes used for behavioral health services (online supplement). These codes came from the Centers for Medicare and Medicaid Services (CMS), the Agency for Healthcare Research and Quality’s Clinical Classification Software,(13) and Berenson-Eggers Type of Service codes for psychiatry.(14, 15) We excluded CPT codes for laboratory tests, medications, provider-to-provider training and education, and ancillary services such as employment, childcare, and legal counseling.

Provider training.

Next, we identified general CPT codes that represent behavioral health care when provided by a behavioral health specialist (online supplement), including evaluation and management codes; neuropsychiatric procedures, tests, and therapies; assessment and treatment of pain; non-specific procedures, treatments or screenings (e.g., HCPCS 4065F: “therapeutic, preventive, or other interventions”), and electrocardiogram. To count as behavioral health care, codes had to be administered by a provider with a behavioral health taxonomy (online supplement). Finally, we limited outpatient care to ambulatory settings by using specific place of service codes for community care and excluding VA-delivered care outside of specific clinics, identified by stop codes (online supplement).

Behavioral health severity and comorbidities.

Because Veterans commonly have more than one behavioral health condition and more than one condition can be treated in a single outpatient visit, we assigned Veterans over the study period and each individual visit to the most severe behavioral health condition group, building off Hunter et al.’s (12) hierarchy of high-cost VA patients with behavioral health conditions, from most severe to least severe: serious mental illness, SUD, PTSD, personality disorders, mood disorders, anxiety disorders, and other behavioral health disorders.

For example, a Veteran treated for PTSD and anxiety in the same visit would be categorized as PTSD. If an outpatient behavioral health visit did not include a behavioral health ICD-10 diagnosis code, we labeled these visits or Veterans as having Non-Behavioral Health Specific Diagnoses. These were mostly diagnoses such as homelessness, counseling, insomnia, headache, etc., that describe services, circumstances, and symptoms frequently associated with behavioral health diagnoses.

For other comorbidities, we calculated a modified Gagne comorbidity score at the Veteran-year level. We modified the algorithms by removing any diagnoses (alcohol, drug abuse, psychoses, and depression) that overlapped with our behavioral health conditions.(16)

Sociodemographic and access characteristics.

For sociodemographic characteristics, we identified the Veteran’s age, sex, race, ethnicity, marital status, and history of homelessness. With respect to healthcare system access, we included distance to VA primary care (outpatient analyses) or secondary care (inpatient analyses), rurality, VA priority group assignment, and health insurance status (VA coverage plus private, Medicare, or Medicaid insurance). VA priority group is a composite score (1–8, highest priority to lowest, respectively) assigned to Veterans receiving VA health care. Priority group scores consider military service, percent service-connected disability, socioeconomic status, qualification for Medicaid, and other VA benefits. All else equal, Veterans in higher VA priority groups may receive care earlier than Veterans in lower VA priority groups and may pay less (if anything) for care. While we controlled for distance, we did not control for hardship (e.g., traveling by boat) given its correlation with distance, or wait time given Veterans are unlikely to be eligible for behavioral health care due to wait time: the MyVA Mental Health Initiative has stipulated same-day appointments since 2016,(17) when our study began.

We also included the following county characteristics: presence of a VA Medical Center (VAMC; outpatient/inpatient) and/or community-based outpatient clinic (outpatient), and ratio of population to behavioral health providers, median income (in thousands), unemployment rate, and poverty rate. In outpatient visit and inpatient stay analyses, we included an index variable for FY of the visit/stay.

Data Analysis.

We compared medical, sociodemographic, and access characteristics between Veterans receiving all their behavioral health care in VA and Veterans receiving some behavioral health community care separately for inpatient and outpatient care. We also compared behavioral health conditions and provider type between VA and community care using the inpatient stay and outpatient visit as the unit of analysis. For these comparisons, we conducted t-tests for continuous variables and chi-squared tests for categorical variables. Given our large sample sizes, we also calculated standardized mean differences (SMDs) to assess the magnitude of differences between means and proportions in VA and community care groups.(18) A SMD of 0.2 has been described as small, 0.5 medium, and 0.8 large.(19) For the multivariate analysis of the association between severity of behavioral health condition and care setting (VA versus community), we used a linear probability model (LPM) due to the large sample size and included facility-level fixed effects due to consistent differences in behavioral health treatment styles and capacity at VA facilities. Because Veterans could have multiple behavioral health visits or stays, we clustered standard errors at the patient level to account for the correlation in characteristics (e.g., gender) within individuals. In sensitivity analyses, a logistic regression model (with random effects for VA facilities and county) for inpatient stays was consistent with the LPM results, though a logistic regression model for outpatient visits did not converge.

We emphasize point estimates and confidence intervals over significance testing when interpreting results, but also provide results of hypothesis tests on a comparisonwise basis based on a 2-sided significance level of 0.05, without adjustment for multiple comparisons. Given the large number of analyses performed, some nominally significant results may reflect type-1 errors, particularly those with p-values close to 0.05. All analyses were performed using SAS Enterprise Guide 8.2.

RESULTS

Behavioral Heath Inpatient and Outpatient Cohort Characteristics

Of the 204,094 Veterans using inpatient behavioral health care between FY16–19, 27% used some community care (Table 1, Figure 1, and online supplement). Compared to Veterans receiving inpatient behavioral health care in VA only, those receiving community care had more severe behavioral health conditions (SMD=0.25) and worse access to care—with greater distance to VA specialty care (SMD=0.22), less health insurance outside VA (SMD=0.21), and less likelihood of having a VAMC in their county of residence (SMD=−0.23), though even these differences were small (i.e., not much over 0.20).

Table 1.

Characteristics of Veterans using only VA or any community care for inpatient behavioral health, fiscal years 2016–2019

Characteristic	Only VA use N=148,284		Any community care use N=55,810		Standardized mean difference	P-value
	N	%	N	%
Individual medical conditions
Behavioral health condition group					0.25	<.001
Serious mental illness	47,037	31.72	21,781	39.03
Substance use disorder	41,759	28.16	16,263	29.14
Post-traumatic stress disorder	13,059	8.81	3,115	5.58
Personality disorders	1,332	0.90	170	0.30
Mood disorders	38,852	26.2	13,237	23.72
Anxiety disorders	2,998	2.02	399	0.71
Other behavioral health disorders	3,247	2.19	845	1.51
Gagne physical health score, mean (M+SD)	1.26±2.14		1.21±1.98		−0.02	<.001
Individual characteristics
Age (M±SD)	51.45±14.89		49.97±14.34		−0.10	<.001
Sex					0.06	<.001
Male	132,261	89.19	48,697	87.26
Female	16,023	10.81	7,106	12.73
Missing	0	0.00	7	0.01
Race					0.02	<.001
American Indian or Alaska Native	1,533	1.03	649	1.16
Asian	1,151	0.78	410	0.73
Black or African American	37,633	25.38	13,637	24.44
Native Hawaiian or other Pacific Islander	1,135	0.77	485	0.87
White	99,563	67.14	37,789	67.71
Multiple races	1,754	1.18	719	1.29
Missing	5,515	3.72	2,121	3.80
Ethnicity					0.04	<.001
Hispanic	9,690	6.53	4,279	7.67
Non-Hispanic	135,181	91.16	50,114	89.79
Missing	3,413	2.30	1,417	2.54
Marital status					0.13	<.001
Married	44,879	30.27	15,265	27.35
Previously married	62,309	42.02	24,006	43.01
Never married	38,596	26.03	14,706	26.35
Missing	2,500	1.69	1,833	3.28
Homelessness					0.09	<.001
Homeless	46,259	31.20	18,997	34.04
Not homeless	97,685	65.88	34,601	62.00
Missing	4,340	2.93	2,212	3.96
Individual access to the healthcare system
Distance to VA specialty care					0.22	<.001
>40 miles	38,580	26.02	19,757	35.40
<= 40 miles	108,080	72.89	34,988	62.69
Missing	1,624	1.10	1,065	1.91
Rurality					0.02	<.001
Urban	108,242	73.00	41,219	73.86
Rural	35,256	23.78	12,855	23.03
Highly rural/Island	1,222	0.82	353	0.63
Missing	3,564	2.40	1,383	2.48
VA priority group assignment					0.15	<.001
1–6 (high priority service – service connected disability or income)	137,687	92.85	52,903	94.79
7–8 (above annual income threshold)	9,556	6.44	2,715	4.86
Missing	1,041	0.70	192	0.34
Health insurance status					0.21	<.001
No health insurance	85,620	57.74	36,104	64.69
Health insurance (private, Medicare, Medicaid)	59,901	40.40	17,501	31.36
Missing	2,763	1.86	2,205	3.95
County Characteristics
VA Medical Center					−0.23	<.001
Yes	72,212	48.70	20,885	37.42
No	76,072	51.30	34,925	62.58
Ratio of population to behavioral health providers in thousands (M±SD)	0.88±1.59		0.97±1.61		0.05	<.001
Median income (M±SD)	58.92±14.80		57.13±13.06		−0.13	<.001
Unemployment rate (M±SD)	4.53±1.24		4.55±1.16		0.02	<.001
Poverty rate (M+SD)	15.26±4.81		15.63±4.87		0.08	<.001

Figure 1.

Percent of Veterans using any community care for behavioral health, fiscal years 2016–2019

Of the 3,467,010 Veterans using outpatient behavioral health care, 4% received some community care between FY16–19 (primarily as dual users of VA and community care; Table 2 and online supplement), with rates increasing over time (Figure 1). Compared to Veterans receiving outpatient behavioral health care in VA only, those receiving some community care had more severe behavioral health conditions (SMD=0.64), were more likely to be female (SMD=0.27), and had higher VA priority status (SMD=0.23); they also had lower comorbidity scores (SMD=−0.24), were younger (SMD=−0.46), and had less health insurance outside VA (SMD=0.24).

Table 2.

Characteristics of Veterans using only VA or any community care for outpatient behavioral health, fiscal years 2016–2019

Characteristic	Only VA use N=3,335,426		Any community care use N=131,584		Standardized mean difference	P-value
	N	%	N	%
Individual medical conditions
Behavioral health condition group					0.64	<.001
Serious mental illness	407,176	12.21	26,428	20.08
Substance use disorder	428,445	12.85	20,264	15.40
Post-traumatic stress disorder	671,222	20.12	45,058	34.24
Personality disorders	14,921	0.45	840	0.64
Mood disorders	555,706	16.66	20,669	15.71
Anxiety disorders	139,192	4.17	3,673	2.79
Other behavioral health disorders	60,756	1.82	1,462	1.11
Non-behavioral health specific diagnoses*	1,058,008	31.72	13,190	10.02
Gagne physical health score (M±SD)	0.95±2.01		0.54±1.39		−0.24	<.001
Individual Characteristics
Age (M±SD)	58.07±17.79		50.34±15.53		−0.46	<.001
Sex					0.27	<.001
Male	2,976,720	89.25	105,196	79.95
Female	358,694	10.75	25,481	19.36
Missing	12	0.00	907	0.69
Race					0.15	<.001
American Indian or Alaska Native	29,674	0.89	1,851	1.41
Asian	35,730	1.07	2,530	1.92
Black or African American	712,943	21.37	22,471	17.08
Native Hawaiian or other Pacific Islander	29,696	0.89	1,716	1.30
White	2,308,833	69.22	91,770	69.74
Multiple races	35,758	1.07	2,158	1.64
Missing	182,792	5.48	9,088	6.91
Ethnicity					0.12	<.001
Hispanic	231,318	6.94	12,502	9.5
Non-Hispanic	2,994,520	89.78	113,437	86.21
Missing	109,588	3.29	5,645	4.29
Marital status					0.09	<.001
Married	1,615,480	48.43	63,913	48.57
Previously married	1,096,465	32.87	39,429	29.96
Never married	566,983	17.00	23,308	17.71
Missing	56,498	1.69	4,934	3.75
Homelessness					0.15	<.001
Homeless	339,084	10.17	11,595	8.81
Not homeless	2,977,822	89.28	119,579	90.88
Missing	18,520	0.56	410	0.31
Individual Access to the Healthcare System
Distance to VA primary care					0.16	<.001
> 40 miles	165,552	4.96	11,532	8.76
<= 40 miles	3,164,488	94.88	119,757	91.01
Missing	5,386	0.16	295	0.22
Rurality					0.15	<.001
Urban	2,292,912	68.74	85,981	65.34
Rural	956,048	28.66	40,235	30.58
Highly rural/Island	35,102	1.05	1,917	1.46
Missing	51,364	1.54	3,451	2.62
VA priority group assignment					0.23	<.001
1–6 (high priority service – service connected disability or income)	2,925,189	87.70	122,871	93.38
7–8 (above annual income threshold)	359,024	10.76	7,195	5.47
Missing	51,213	1.54	1,518	1.15
Health insurance status					0.24	<.001
No health insurance	1,408,595	42.23	67,703	51.45
Health insurance (private, Medicare, Medicaid)	1,856,243	55.65	59,260	45.04
Missing	70,588	2.12	4,621	3.51
County Characteristics
VA Medical Center or Community-Based Outpatient Clinic					0.14	<.001
Yes	2,352,547	70.53	91,184	69.30
No	960,622	28.80	39,601	30.10
Missing	22,257	0.67	799	0.61
Ratio of population to behavioral health providers in thousands (M±SD)	1.00±1.71		0.84±1.29		−0.10	<.001
Median income in thousands (M±SD)	58.73±14,72		60.27±14.57		0.10	<.001
Unemployment rate (M±SD)	4.47±1.24		4.45±1.34		−0.01	<.001
Poverty rate (M±SD)	15.11±4.89		14.88±4.58		−0.05	<.001

^*These are mostly diagnoses such as homelessness, counseling, insomnia, headache, etc., that describe services, circumstances, and symptoms that are frequently associated with a particular mental health diagnosis.

Unadjusted VA and Community Care Behavioral Health Utilization

From FY16–19, 80% percent of the 448,648 inpatient behavioral health stays occurred in VA and 20% occurred in the community (online supplement), while 97% of more than 55 million outpatient behavioral health visits occurred in VA and 3% occurred in the community (online supplement). The distribution of treated behavioral health conditions differed considerably within inpatient and outpatient care and across care settings. In particular, for inpatient stays, more severe conditions were treated in VA than in the community, while there was no clear pattern for outpatient care (online supplement).

Provider Training

There was also larger variability by provider type for outpatient visits in VA than in the community (SMD=1.06; Table 3). There was a greater presence of highly-trained specialists, namely psychiatrists/behavioral neurologists (22% vs. 10%) and psychologists (25% vs. 18%) treating Veterans in VA vs. those treating Veterans in the community, along with a greater presence of social workers in VA (36% vs. 15%). For care in the community, the dominant provider type for outpatient behavioral health visits was counselors/therapists at 40% compared to 7% in VA. The top two services provided in VA outpatient visits were group psychotherapy (14%) and individual psychotherapy for 60 minutes (9%) (online supplement). Individual psychotherapy for 60 minutes was the most common service provided in the community (47%), and methadone administration was second most common (15%) (online supplement).

Table 3.

Type of provider for Veterans behavioral health outpatient visits by VA and community care, fiscal years 2016–2019

	VA visits		Community care visits
	N	%	N	%
Psychiatry and behavioral neurology	11,769,045	22.06	172,661	10.18
Psychology	13,574,507	25.45	306,056	18.04
Behavioral health advanced practice providers	2,818,914	5.28	45,048	2.65
Behavioral health counseling and therapy	3,799,639	7.12	681,181	40.14
Behavioral health social worker	19,154,090	35.9	246,609	14.53
Psychiatric pharmacist	176,647	0.33	8,217	0.48
Other	2,053,889	3.85	237,104	3.97

Note: standardized mean difference = 1.06

Adjusted Probabilities for Behavioral Health Utilization in VA or Community Care

For inpatient behavioral health, Veterans with PTSD, personality disorders, and anxiety disorders had a significantly lower probability of receiving community care, while Veterans with mood disorders had a significantly higher probability of getting purchased care in the community versus VA (Table 4). Additionally, Veterans who were older, male, Asian (vs. White), closer to a VA, in rural or highly rural areas, with health insurance, or receiving services in FY19 (vs. FY16), had significantly lower probabilities of using community care versus VA for an inpatient behavioral health stay. Veterans who were Native Hawaiian or Other Pacific Islander, non-Hispanic, not homeless, and with a high VA priority group assignment had a significantly higher probability of using community care than VA for an inpatient behavioral health stay. These results were consistent with logistic regression results (online supplement).

Table 4.

Regression analyses predicting behavioral health outpatient visits and inpatient stays in VA-purchased community care

Characteristic	Community care inpatient stay		Community care outpatient visit
	Probability	95% CI	Probability	95% CI
Medical conditions
Behavioral health condition group (ref=other behavioral health disorders)
Serious mental illness	.000	−.010, .010	−.023	−.026, −.021
Substance use disorder	.000	−.010, .010	−.002	−.005, .001
Post-traumatic stress disorder	−.053	−.065, −.042	−.004	−.006, −.001
Personality disorders	−.117	−.130, −.104	−.015	−.019, −.011
Mood disorders	.037	.027, .047	−.002	−.004, .001
Anxiety disorders	−.066	−.079, −.053	−.004	−.007, −.002
Non-behavioral health specific diagnosis	N/A	N/A	−.029	−.031, −.027
Gagne physical health score	−.002	−.002, −.001	−.000	−.000, −.000
Sociodemographic characteristics
Age (in years)	−.033	−.047, −.018	−.000	−.002, .001
Male (ref=female)	−.033	−.047, −.018	−.011	−.015, −.007
Race (ref=White)
American Indian or Alaska Native	−.024	−.039, −.009	−.008	−.010, −.007
Asian	−.024	−.039, −.009	−.006	−.010, −.002
Black or African American	−.004	−.021, .013	−.005	−.010, −.001
Native Hawaiian or other Pacific Islander	.009	.005, .014	−.009	−.010, −.007
Multiple races	.002	−.005, .009	−.005	−.007, −.003
Non-Hispanic (ref=Hispanic)	.011	.007, .014	.003	.002, .004
Marital status (ref=never married)
Married	.002	−.002, .007	.001	−.004, .006
Previously Married	.002	−.002, .007	.003	.001, .004
Not Homeless (ref=Homeless)	.019	.016, .022	.016	.015, .017
Access to healthcare systems
Distance to VA Primary/Secondary Care No (<= 40 miles) (ref = Yes (>40 miles))	−.054	−.055, −.053	−.032	−.032, −.032
Rurality (ref=Urban)
Rural	−.030	−.030, −.029	−.005	−.005, −.005
Highly rural	−.061	−.062, −.059	−.007	−.008, −.007
VA priority group assignment High priority service (ref=Above annual income threshold)	.014	.010, .018	.001	.001, .002
Health insurance (ref=no health insurance)	−.046	−.067, −.025	−.004	−.016, .008
County characteristics
VA Medical Center or Community-Based Outpatient Center (ref=no)	−.002	−.023, .019	.006	−.006, .018
Ratio of population to behavioral health providers	−.002	−.023, .019	−.002	−.014, .010
Median income	−.000	−.030, .030	−.001	−.013, .012
Unemployment rate	−.003	−.060, .054	−.000	−.014, .013
Poverty rate	−.001	−.038, .036	−.001	−.016, .014
Fiscal year (ref=FY2016)
2017	.005	−.006, .015	.008	−.005, .021
2018	.005	−.006, .015	.017	−.001, .034
2019	−.018	−.032, −.004	.026	.012, .040
Intercept	−.079	−.107, −.050	.143	.129, .157

Note: Text is bolded when p<.05.

Veterans with serious mental illness, PTSD, personality disorders, anxiety disorders, and non-behavioral health specific diagnoses had a significantly lower probability of seeking outpatient behavioral health care in the community versus VA than Veterans with other behavioral health disorders (Table 4). Additionally, Veterans who were male, racial minorities (vs. White), who lived nearer to VA primary care or in rural or highly rural areas, had significantly lower probabilities of using community care than VA for outpatient behavioral health care. Veterans who were non-Hispanic, previously married (vs. never married), not homeless, with high VA priority status, or receiving services in FY19 (vs. FY16) had significantly higher probabilities of using community care than VA for outpatient behavioral health care.

DISCUSSION

While a small amount of prior literature has examined use of behavioral health care by Veterans in VA and Medicare(3) or Medicaid,(7) this study uniquely examines behavioral health care delivered or purchased by VA following the Choice Act of 2014, which vastly increased community care. Additionally, the current study includes approximately 3.5 million VA users of both inpatient and outpatient behavioral health care, while the VA-Medicare study was limited to about 15,000 VA primary care users and the VA-Medicaid study was limited to about 7,000 non-elderly Veterans with behavioral health conditions.

Thus, the current study provided a broad view of behavioral health utilization in VA-delivered and VA-purchased community care for the entire VA-enrolled population, while adjusting for non-VA coverage through public or private health insurance in predictive models. In line with our first hypothesis, we found that a substantial portion of inpatient behavioral health care was provided in the community (20%), with a smaller portion of outpatient behavioral health care provided in the community (3%). Our second hypothesis, that more severe behavioral health conditions would be treated in the VA than in the community, was supported for inpatient care, but not for outpatient care, where a clear pattern did not emerge. This is likely due to a larger portion of outpatient behavioral health visits in VA without a specific behavioral health diagnosis when compared to community care (21% vs. 4%), which could be related to different coding practices in VA versus the community, where more diagnoses tend to be documented.(20) As we anticipated, a larger portion of behavioral health care was provided by clinicians with more years of clinical training in VA than in the community.

We also observed more group therapy provided in VA than in the community. This difference is likely due to VA’s focus on peer support for treatment, its need to meet access standards, and its relative absence of fee-for-service incentives to provide individual care compared to community settings. We also found higher rates of methadone prescribing in the community than in VA, which is not surprising as VA runs very few opioid treatment programs authorized to prescribe methadone(21, 22); further, Veterans can more easily meet the requirement for multiple methadone maintenance visits each week through the closer proximity of community providers. In summary, these results demonstrate that while a small portion of VA enrollees use outpatient behavioral health care in the community, there is demand for psychotherapy and alcohol/drug services that will require good coordination between VA and the community. Additionally, with one-fifth of inpatient behavioral health stays occurring in the community, it is critical that information about these admissions flows back to VA so that appropriate follow-up care occurs.

Differences in utilization patterns for VA-delivered and VA-purchased behavioral health care reflect Veterans’ choice and supply of behavioral health care. An eligible Veteran can receive care from any Community Care Network (CCN) provider willing to accept Medicare payment rates and not suspended by CMS. VA itself cannot engage in selective contracting, although it could encourage the third-party administrators who oversee the CCN to do so.

A limitation of this work is that it is possible that VA providers code care differently than community providers. Whether coding practices would attenuate or exacerbate the differences we see is not immediately known.

We expect that broader eligibility criteria in the MISSION Act will increase the number of Veterans seeking VA-purchased behavioral health care. Thus, differences in military cultural competence and training in evidence-based treatment need to be addressed.(8, 9) In response to the MISSION Act (Sections 123, 131, and 133), trainings are available through VHA Training Finder Real-Time Affiliate Integrated Network MISSION Act Curriculum on topics such as PTSD, opioids, and military cultural awareness.(23) Additionally, VA clinicians and staff from VA’s Office of Mental Health and Suicide Prevention created a Community Provider Toolkit with sections on asking about military experience, working with Veteran populations, supporting Veteran mental health and wellness, and navigating Veteran benefits and services.(24) VA’s National Center for PTSD and Rocky Mountain Mental Illness Research, Education, and Clinical Centers also respectively offer free consultation on PTSD and suicide risk management for community providers working with Veterans.(25, 26) Thus, there are opportunities for community care providers to leverage VA resources on Veteran-specific behavioral health needs.

CONCLUSIONS

As demand for behavioral health care outpaces supply, VA may need to leverage community care to meet behavioral health needs and optimize Veteran care. This is the first study to illustrate how much behavioral health care is VA-delivered and VA-purchased—a first step in assessing VA enrollees’ demand for and providers’ supply of behavioral health care. Understanding differences in VA-delivered and VA-purchased community care provides an opportunity to help Veterans receive high-quality behavioral health care. Future studies should assess the consequences of dual use of VA-delivered and purchased behavioral health care, along with the health outcomes, quality, timeliness, and cost of care in the community to ensure that it meets or exceeds VA standards.

Highlights.

• Within the Veterans Health Administration (VA), more than a quarter of Veterans receiving inpatient behavioral health care utilized VA-purchased community care, with severe behavioral health conditions more frequently treated in VA than in community inpatient settings.

• While only 4% of VA-enrolled Veterans receiving outpatient behavioral health care utilized community care, these Veterans saw less highly-trained providers than those receiving care in VA and received more individual vs. group therapy.

• Coordination between VA and community care providers is needed to ensure continuity and quality of outpatient behavioral health care as well as follow-up care after inpatient behavioral health stays.