Depression in general medical settings. Implications of three health policy studies for consultation-liaison psychiatry

Prepaid or prospective reimbursement has implications for the consultation-liaison (C-L) psychiatrist. The author reviews results from three health policy studies that indicated 1) degree of reliance on general medical providers for mental health care is not affected by generosity of fee-for-service (FFS) coverage, but is greater in some prepaid health care systems; 2) psychological sickness of depressed outpatients visiting general medical providers is similar across prepaid and FFS systems of care; 3) prepaid care is associated with lower rates of detection of depression and counseling in the general medical sector; 4) depression outcomes in the general medical sector are similar under prepaid or FFS care; 5) quality of care for depressed patients is moderate to low in the general medical sector; and 6) depressed elderly inpatients receive higher quality of psychological care in psychiatric units, but they receive higher quality of physical care in general medical wards. The discussion emphasizes the C-L psychiatrist's role in educating general medical providers, improving outcomes for the sickest patients, and improving psychosocial care in prepaid practices.     

Informing the policy process: from efficacy to effectiveness data on pharmacotherapy

Health care delivery is rapidly changing, but are the right data available to inform the policy process? This article illustrates the use of observational data on quality and effectiveness of treatment for anticipating the consequences of alternative forms of health care delivery, with psychotropic medications used as the example. The data are from the Medical Outcomes Study. Patients in each specialty sector (general medical provider, psychiatrist, psychologist or master's-level therapist) have unique profiles of use of appropriate psychotropics, and there is less appropriate and less efficient medication management in prepaid than fee-for-service care, especially within psychiatry. Overall, effective psychotropic medications are underused, reducing the cost-effectiveness of care. Improving the quality of psychotropic medication management would improve patient functioning outcomes and cost effectiveness of care, but in the absence of compensating strategies, it would also raise treatment costs.     

Patterns of ambulatory health care in five different delivery systems

Few empirical investigations permit systematic comparison of the impact of widely-varying delivery systems within a single population sample. This study provides such a comparison, describing patterns of ambulatory care among patients using five different systems in Washington, D.C. as a regular source of health care: solo practice, fee-for-service group practice, prepaid group practice, public clinics, and hospital outpatient departments or emergency rooms. Comparisons are adjusted statistically to account for major patient group variations, and the results reveal substantial differences among the five systems. Sources used primarily by the poor--hospital outpatient departments, emergency rooms, and public clinics--contained important structural and financial barriers, and had the lowest rates of patient-initiated use. The prepaid system, in contrast, maximized patient's access to both preventive care and symptomatic care, and did not seem to inhibit physician-controlled follow-up care. The results suggest some perverse effects of fee-for-service payment: patients, especially poor patients, appeared to be deterred from seeking preventive and symptomatic care, while physicians were encouraged to expand follow-up services. Moreover, services in fee-for-service systems were distributed less equitably relative to both income and medical need than in the prepaid system. These findings have direct implications for policy decisions concerning organizational and financial arrangements for the delivery of ambulatory care.     

Health maintenance organizations and children with special health needs. A suitable match?

OBJECTIVE: To address how well health maintenance organizations (HMOs) meet the needs of almost 700,000 children with disabilities due to chronic conditions enrolled in these plans. DESIGN: A cross-sectional survey. MEASUREMENTS/MAIN RESULTS: Health maintenance organizations offered better protection than conventional plans against out-of-pocket expenses and were much more likely than fee-for-service plans to cover ancillary therapies, home care, outpatient mental health care, and medical case management. In addition, few HMOs maintained exclusions for preexisting conditions. Other aspects of HMO policies, however, were found to operate against the interest of families with chronically ill children. In particular, HMOs commonly made specialty services available only when significant improvement was expected within a short period. Also, HMOs typically placed limits on the amount and duration of mental health, ancillary services, and certain other services frequently needed by chronically ill children. Probably the most serious problems for chronically ill children enrolled in HMOs were the lack of choice among and access to appropriate specialty providers. PARTICIPANTS: Individual HMO plans. SELECTION PROCEDURE: A sample of 95 geographically representative HMOs were selected; 59 (62%) responded. INTERVENTIONS: None. CONCLUSIONS: Health maintenance organizations offer several advantages over traditional fee-for-service plans for families whose children have special health needs. However, the results also indicate that HMOs do not always operate effectively as service provision systems for these children. To a large extent, the availability and quality of services available to a child with special needs is likely to depend on the parents' ability to maneuver within the system.     

Typhoid fever--important issues still remain

The medicare population represents the most important group of covered lives to most providers. Medicare is now pushing seniors to join risk-based plans, and is encouraging providers to form PSOs to contract directly with Medicare for risk-based contracts. By eliminating the commercial HMOs as the middlemen, PSOs can not only control their own destiny as providers, they can retain the risk 'profit' in the community for enhanced services or higher payments to providers. To be successful, however, PSOs must have in place the key elements to manage the organization in a managed care environment. While the task of creating a PSO can appear daunting and the risk can be real and substantial, every provider organization should examine the potential of starting or joining a PSO. The greatest risk could be the risk of doing nothing, which could lead to loss of control of the Medicare population, decreased utilization, declining payment for services, the loss of patients being directed to other providers, and the loss of the risk premium from Medicare capitation.     

Sharing care: the psychiatrist in the family physician's office

OBJECTIVE: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. METHOD: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. RESULTS: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. CONCLUSIONS: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.     

The CHAMPUS Reform Initiative in Hawaii: Reestablishing a medical monopoly.

Examined the effect of the Civilian Health and Medical Plan of the Uniformed Services (CHAMPUS) Reform Initiative (CRI) in Hawaii. Data are presented from 1986–1991 on the professions involved, outpatient and inpatient services rendered, and psychotherapy fees by profession. This "medical gatekeeper" model of managed care, based on a system of referral to specialist services by primary care physicians and developed by a Hawaii medical group, yielded predictable results. Whereas psychologists had been the dominant providers of outpatient mental health services since 1980 and had a minor presence in inpatient services, the implementation of CRI resulted in psychiatrists becoming the dominant outpatient provider and psychologists essentially being eliminated from hospital practice. These results should alert psychologists to the danger of extinction from medical monopolies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Medicaid and non-Medicaid prenatal care by nurse-midwives. Comparison of risk, time, care coordination, and reimbursement

The purpose of the study was to compare high-risk pregnant women with medical assistance payment (HRMA) and those with private insurance payment (HRPI) on use of provider time, care coordination activities, and financial reimbursement. Comparisons were also conducted for the same factors between the high-risk and low-risk women (LRMA) that received medical assistance payment for their care. Total time spent by care providers in giving antepartum, intrapartum, and postpartum care was highest for the HRPI women. However, the two medical assistance groups started prenatal care significantly later and had fewer visits, and one-third did not return for their 6-weeks postpartum visit. The HRPI group also had a higher cesarean birth rate. Rates of care coordination activities such as calls, referrals, and consultations were significantly higher for the HRPI and HRMA women compared with those for the LRMA women. However, the HRMA women have limited financial and psychosocial resources that require additional provider management and referrals. Reimbursement rate was highest for the HRPI group in which approximately 73% of the total amount billed was collected compared with approximately 56% among medical assistance women. Recommendations for policy, practice, and further research are offered.     

Marital distress and mental health care service utilization.

Objective: This study was designed to evaluate the association between marital distress and mental health service utilization in a population-based sample of men and women (N = 1,601). Method: The association between marital distress and mental health care service utilization was evaluated for overall mental health service utilization and for specific sectors of treatment providers, including psychiatrist, other mental health provider, other medical provider, and religious services provider. Interviews were used to assess past-year service utilization and presence of anxiety, mood, and substance use disorders. Results: Approximately 12% of married individuals sought help for problems with their emotions, nerves, or substance use during the 12 months preceding the interview. Marital distress was significantly associated with (a) overall mental health service utilization and service utilization provided by each of the sectors of providers when controlling for demographic variables and (b) overall mental health service utilization and receiving treatment from a psychiatrist when additionally controlling for past-year anxiety, mood, or substance use disorders. There was little evidence that the associations between marital distress and service utilization were moderated by gender or presence of psychiatric disorders. Conclusion: The finding that marital distress is associated with greater mental health care service utilization suggests that clinicians should assess both individual and relationship factors among individuals presenting for treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethical challenges in the managed practice of obstetrics and gynecology

Obstetrics and gynecology has been transformed from a fee-for-service, unmanaged system to a prepaid managed system. This change poses significant ethical challenges, which we address. We show that obstetrician-gynecologists and medical institutions are moral co-fiduciaries of female and pregnant patients, that the obstetrician-gynecologist should be economically disciplined without capitulating to managed care, and that managed care organizations have an obligation to support the medical education and research from which they benefit.     

How expensive is unlimited mental health care coverage under managed care?

OBJECTIVES: To study costs, access, and intensity of mental health care under managed care carve-out plans with generous coverage; compare with assumptions used in policy debates; and simulate the consequences of removing coverage limits for mental health care as required by the Mental Health Parity Act. DESIGN: Claims data from 1995 and 1996 for 24 managed care carve-out plans; all plans offered unlimited mental health coverage with minimal co-payments. OUTCOME MEASURES: Probability of care, intensity of care, and total costs broken down by service type and type of enrollee. RESULTS: Assumptions used in last year's policy debate overstate actual managed care costs by a factor of 4 to 8. In the plans studied, costs are lower owing to reduced hospitalization rates, a relative shift to outpatient care, and reduced payments per service. However, access to mental health specialty care increased (7.0% of enrollees) compared with the preceding fee-for-service plans (6.5%) or free care in the RAND Health Insurance Experiment (5.0%). Removing an annual limit of $25000 for mental health care, which is the average among plans currently imposing limits, will increase insurance payments only by about $1 per enrollee per year. Children are the main beneficiaries of expanded benefits. CONCLUSIONS: Concerns about costs have stifled many health system reform proposals. However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates. For mental health care, the cost consequences of improved coverage under managed care, which by now accounts for most private insurance, are relatively minor.     

The impact of payor/provider type on health care use and expenditures among the frail elderly

OBJECTIVES: This study examined whether health care expenditures and usage by the frail elderly differ under three payor/provider types: Medicare fee for service, Medicare health maintenance organization (HMO), and dual Medicare-Medicaid enrollment. METHODS: In-home interviews were conducted among 450 frail elderly patients of a San Diego, Calif, health care system. Cost and use data were collected from providers. RESULTS: Analyses revealed no difference in total expenditures between fee-for-service and HMO enrollees, but Medicare-Medicaid beneficiaries' expenditures were 46.8% higher than those for HMO enrollees and 52.2% higher than those for the fee-for-service group. Fee-for-service participants were less than half as likely as HMO enrollees to have two or more hospital admissions, but hospital usage rates between those two payor/provider groups did not differ. Not were there payor/provider differences in access to home health care, but HMO home health care users received significantly fewer services than the others. CONCLUSIONS: The care provided to these HMO beneficiaries resulted in a combination of restricted home health use and higher multiple hospitalizations. This raises compelling questions for future research. For the dually enrolled, stronger cost containment may be required.     

Mental health services in managed care: quality questions remain

Primary care physicians are often the professionals to whom older patients turn for advice about medical coverage in Medicare managed care health plans. To assist in this dialogue, these authors outline current characteristics and financial arrangements for psychiatric and mental health services in Medicare managed care. Advantages and disadvantages of Medicare managed care for enrollees with mental disorders are outlined. Mental health "carve-out" and "carve-in" models are defined, and questions are raised about the number of psychiatrists and other mental health care providers needed to provide appropriate care for a plan's enrollees.     

Induction of Th2 cell differentiation in the primary immune response: dendritic cells isolated from adherent cell culture treated with IL-10 prime naive CD4+ T cells to secrete IL-4

Rates of hormone replacement therapy (HRT) in women have varied substantially over the last 25 years. Data on the impact of recent recommendations for widespread use to prevent cardiovascular disease and osteoporosis and factors that influence use are needed. We attempted to (1) describe recent trends in HRT use, (2) investigate the relationship between HRT use and prepaid drug benefit, and (3) detail prescribing frequencies by provider specialty. We conducted a cross-sectional analysis of annual HRT pharmacy dispensings from 1986 to 1995 in a large HMO to all female HMO members aged 45 years and older. HRT rates increased among all age categories, although the magnitude of change varied by age. Highest rates of use were found in those 50-59 years old. Although combined estrogen-progestin use increased, 57% of all estrogen users did not receive progestin in 1995. Unopposed estrogen use was largely limited to hysterectomized women. Women of all ages with no prepaid drug benefit as part of their HMO coverage had the lowest HRT rates. Internal medicine, obstetrics/gynecology, and family practice providers prescribed over 90% of HRT, and prescriber specialty varied with user age. HRT use increased in the HMO from 1986 to 1995, especially among younger women. In 1995, about half of women aged 50-64 years received one or more HRT dispensings. As the benefits, risks, and cost effectiveness of HRT depend on the duration of use, additional information on current use duration is needed. Combined estrogen-progestin use increased and appeared appropriate to hysterectomy status. Research is needed to determine if lower HRT use rates among women without a prepaid drug benefit indicate less prophylactic HRT use, particularly among younger women, for whom this lack of coverage was relatively common.     

Variations in the management of primary care: effect on cost in an HMO network

OBJECTIVE: To determine the relation to cost of different aspects of the management of primary care among group practices within a health maintenance organization network. MEASURES: A cross-sectional survey study of medical practices conducted with Blue Cross Blue Shield of Minnesota, St Paul. The subjects were group practices accepting financial and administrative responsibility for primary care services in the managed care plans of Blue Cross Blue Shield of Minnesota. One hundred twelve primary care practices and 153397 enrollees were included in this analysis. The principal resource use measure in this study was nonhospital cost per member per year estimated from payments to providers plus subscriber-eligible liability. RESULTS: The medical directors' responses revealed considerable variability in the management of primary care in these 112 practices. Group practice characteristics consistently associated with lower nonhospital cost were patient identification of a primary care physician, cost of care profiling, more frequent physician profiling, more patients per hour in the clinic, a higher proportion of primary care physicians in the specialty of family or general practice, and a greater number of physicians in the group practice. CONCLUSIONS: Results of this study demonstrate substantial variation in the management of primary care among group practices participating in a health maintenance organization network. These differences are associated with significant variation in the nonhospital cost of care for enrollees.     

Managed care and the survival of neurology referral centers. A commitment to centers of excellence

Since the collapse of federal health system reform legislation in 1994, there has been a growing concern with the quality of care provided within managed care systems. Just as physicians practicing under a traditional fee-for-service payment base have financial incentives to do as much as possible for each patient (doing well by doing good), physicians working for managed care plans are sometimes given perverse incentives to do as little as possible. A major quality-related concern among patients and payers (often referred to jointly and ambiguously as consumers of care) is the much larger role assigned to primary care physicians in managed care plans than is usually the case with traditional indemnity insurance.     

Beneficiary choice and interprofessional participation in CHAMPUS mental health services: 1980–1987.

As a major health plan with freedom of choice of provider, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) yields natural experiments in fee-for-service practice that are relevant to mental health policy. This is seen in the extent to which (1) beneficiaries use multiple mental health providers or a single (exclusive) provider, (2) psychiatrists have been replaced as the major provider, (3) general physicians are increasingly involved, and (4) psychologists have penetrated this market over the years 1980–1987, including some inpatient practice and the emergence of a general physician/psychologist alliance. The cost and public policy aspects are discussed against an empirical background. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of Department of Veterans Affairs primary care patients with posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is common among Veterans Affairs (VA) primary care patients and may be managed via multiple treatment pathways. Using the Behavioral Model of Health Service Use (Anderson, 1995), this retrospective study based on medical chart review examined factors associated with three types of mental health treatment: intervention by a 1) primary care provider (PCP), 2) primary care-mental health integration (PC-MHI) provider, and 3) specialty mental health (SMH) provider. A second goal was to describe PTSD treatment services for patients not receiving SMH by detailing the content of mental health treatment provided by PCPs and PC-MHI providers. Electronic medical record data for a five year time period for 133 Veterans were randomly selected for review from a population 6,637 primary care patients with PTSD. Results indicated that the evaluated needs of participants (i.e., number of unique medical and psychiatric disorders) were associated with Veterans receiving more intensive services (i.e., SMH). PCPs commonly addressed patients' mental health concerns, but patients often declined referrals for mental health treatment. PC-MHI consultations most often focused on medication management and supportive psychotherapy. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The effect of cost sharing on the use of chiropractic services

OBJECTIVES: Chiropractic care is increasing in the United States, and there are few data about the effect of cost sharing on the use of chiropractic services. This study calculates the effect of cost sharing on chiropractic use. METHODS: The authors analyzed data from the RAND Health Insurance Experiment, a randomized controlled trial of the effect of cost sharing on the use of health services. Families in six US sites were randomized to receive fee-for-service care that was free or required one of several levels of cost sharing, or to receive care from a health maintenance organization (HMO). Enrollees were followed for 3 or 5 years. All fee-for-service plans covered chiropractic services. Persons assigned to the HMO experimental group received free fee-for-service chiropractic care; persons in the HMO control group had 95% cost sharing for chiropractic services. The authors calculated the mean annual chiropractic expense per person in each of the fee-for-service plans, and also predicted their chiropractic expenditures using a two-equation model. Chiropractic use among persons receiving HMO and fee-for-service care were compared. RESULTS: Chiropractic care is very sensitive to price, with any level of coinsurance of 25% or greater decreasing chiropractic expenditures by approximately half. Access to free chiropractic care among HMO enrollees increased chiropractic use ninefold, whereas access to free medical care decreased fee-for-service chiropractic care by 80%. CONCLUSIONS: Chiropractic care is more sensitive to price than general medical care, outpatient medical care, or dental care, or and nearly as sensitive as outpatient mental health care. A substantial cross-price effect with medical care may exist.