skip to page content
Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

Health Systems Research

Go to the VA ORD website
Go to the QUERI website

PPO 13-380 – HSR Study

PPO 13-380
Fee Basis vs. in-VA Mental Health Care for Veterans
Alyssa Mansfield Damon, PhD MHA MPH
VA Pacific Islands Health Care System, Honolulu, HI
Honolulu, HI
Funding Period: October 2014 - September 2015
The number of Veterans diagnosed with mental health conditions and seeking VA treatment has increased in recent years, with expectations of continued growth. The most prevalent psychiatric diagnoses include depression, posttraumatic stress disorder (PTSD), and substance use disorders (SUDs), with many Veterans receiving two or more concurrent mental health diagnoses. Preferred treatment for these conditions typically involves continuous clinical intervention, yet some Veterans may not get the services needed at their nearest VA facility due to factors such as geographic access, availability of specialty care, and ability to schedule timely appointments with providers. Despite significant growth in both Veterans needing mental health services and reliance upon Fee Basis Care for these conditions, published information on utilization of Fee Care for mental health is lacking. Namely, it is unclear if variation between Fee Basis and in-VA utilization of mental health treatment services and growth of Fee Basis mental health care over time is attributable to facility features such as adequate staffing of urban/rural providers and caseloads, or patient characteristics such as location, gender, or comorbid mental health conditions. Research focusing on the Fee Program in general, and its use for mental health specifically, are sorely needed.

The objectives of this study are to: (a) examine variability among VA facilities in the proportion of Veterans receiving Fee Basis mental health care, (b) determine if certain demographic or clinical characteristics explain within-facility variation in receipt of only Fee Basis, only in-VA, or mixed in-VA/Fee Basis mental health care, and (c) identify facility-level characteristics associated with growth from FY02 to FY12 in the use of Fee Basis Care for mental health.

To achieve these objectives, we will leverage VA administrative data to query medical records and examine factors related to setting of care for mental health treatment among Veterans receiving care within the VA healthcare system. Veterans will be selected from all VA healthcare systems and will be eligible based upon having two or more visits with a primary or secondary ICD-9 diagnosis code for depression, posttraumatic stress disorder (PTSD), or substance use disorders (SUD) between FY02 and FY12. These conditions 1) represent the three most prevalent psychiatric conditions for which Veterans receive any mental health services in the VA; 2) represent the three most prevalent diagnoses for Fee Basis mental health care; and 3) co-occur in many VA patients. We expect the resulting data set to contain study information for between 2.5 and 3 million Veterans. Using a series of generalized linear models, we will examine how demographic variables (e.g., gender, age, race/ethnicity, city/state/zip code of Veteran, military period of service), medical data (e.g., diagnostic codes, dates of medical visits), and facility-level information (e.g., name, location, and size of facility where care was received) are associated with in-VA vs. Fee Basis Care for depression, PTSD, and SUD. Multilevel models will also be considered for analysis of Veterans within different service catchment areas to account for similarities of Veterans, available VA services, and common care practices within the same VA facility.

None to report at this time.

By examining Fee Basis mental health care, the VA can likely determine when community-based care may benefit both the Veteran and VA by serving as another delivery option, and when it may represent inappropriate reliance on external resources that would be better delivered within the VA network. This information may identify potential health care system gaps and opportunities to ultimately meet the treatment needs of Veterans while preserving quality and cost.

External Links for this Project

NIH Reporter

Grant Number: I21HX001503-01A1

Dimensions for VA

Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.

Learn more about Dimensions for VA.

VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address.
    Search Dimensions for this project


Journal Articles

  1. Blonigen DM, Macia KS, Bi X, Suarez P, Manfredi L, Wagner TH. Factors associated with emergency department useamong veteran psychiatric patients. The Psychiatric quarterly. 2017 Dec 1; 88(4):721-732. [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: none
MeSH Terms: none

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.