Access to public mental health services - Determinants of population coverage

OBJECTIVES. This study examined factors that affect access to Veterans Administration mental health services. METHODS. Data from national Veterans Affairs databases and the 1990 Decennial Census were used to estimate rates of Veterans Affairs mental health service use in each US county (n = 3,156) among all US veterans and in three subpopulations defined by eligibility and clinical status. Independent variables examined in standard multivariate analyses and using hierarchical linear modeling techniques included county-level sociodemographic characteristics (age, race, and income); "unmanaged" service system characteristics (those not directly controlled by Veterans Affairs program managers, eg, distance from residence to Veterans Affairs and to non-Veterans Affairs services, local supply of non-Veterans Affairs services); and "managed" service system factors (those directly controlled by Veterans Affairs program managers, eg, per capita Veterans Affairs funding level and the efficiency of Veterans Affairs service delivery). RESULTS. Altogether, 2.0% of US veterans used Veterans Affairs mental health services. More than one third (36%) of the variance in utilization was explained by sociodemographic factors; 8% was explained by unmanaged service system factors and 7% was explained by managed service system factors, with variations among subgroups. Substitution effects were demonstrated between Veterans Affairs and non-Veterans Affairs systems and appeared to be diagnosis-specific. CONCLUSIONS. Both per capita funding levels and efficient service delivery were significantly associated with increased access to mental health services. Implications for health system performance assessment and management are discussed.