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Publication Briefs

Mental Health Integration in VA Primary Care Settings Increased Access to Care — and Costs

For most patients suffering from mental health symptoms, primary care is the starting point for assessment and potential treatment. Yet without timely, accessible mental health specialist back-up, primary care clinicians may not be able to engage these patients in appropriate mental healthcare. This led VA to co-locate and integrate mental health specialists in primary care nationally through the Primary Care-Mental Health Integration Program (PC-MHI) beginning in 2007, but the return on investment for PC-MHI at a national level is unknown. Thus, this retrospective cohort study examined PC-MHI's effects on healthcare use and cost patterns among 5.4 million primary care patients in 396 VA clinics (FY2014-FY2016), while also accounting for the implementation of VA's Patient Aligned Care Team (PACT) model of care. Investigators assessed VA outpatient and inpatient care and total cost of VA care as a function of attending a clinic with a high vs. low PC-MHI penetration rate — a VA performance indicator of PC-MHI's reach into a clinic's primary care patient population. Clinic and patient characteristics were also examined, including demographics, psychiatric and medical diagnoses, homelessness, and travel distance to clinic.


  • Veterans treated in VA clinics with higher proportions of primary care patients seen by PC-MHI providers received more outpatient care than those treated in clinics with lower PC-MHI penetration, but at a higher total cost.
    • Each percentage-point increase in the proportion of clinic patients seen by PC-MHI providers was associated with 11% more mental health and 40% more primary care visits, but also 9% higher average total costs per patient per year.
  • Among patients with serious mental illness, increasing PC-MHI penetration was associated with greater use of specialty-based mental health and all other healthcare visits.
  • Among patients seen in hospital-based clinics, increasing PC-MHI penetration was associated with fewer emergency visits per person per year.


  • VA has achieved its initial goal of increasing overall access to mental healthcare nationally for primary care patients while maintaining access to specialized care for those with serious mental illness. However, successful implementation of integrated care led to higher total costs, due to an increase in outpatient visits. Future research also might assess the effect on short-term costs.


  • Study results did not include medical care received outside VA.
  • Investigators did not control for mental healthcare staffing, which may impact healthcare use/costs.
  • Coding inaccuracies may have occurred during transition from ICD-9 to ICD-10 diagnostic codes.

This study was partly funded by HSR&D. Dr. Leung is part of HSR&D's Center for Healthcare Innovation, Implementation and Policy (CSHIIP), and Dr. Yoon is part of HSR&D's Health Economics Resource Center (HERC)

PubMed Logo Leung L, Rubenstein L, Yoon J, et al. Veterans Health Administration Investments in Primary Care and Mental Health Integration Improved Care Access. Health Affairs. August 2019;38(8):1281-1288

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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