Provider choice and continuity for the treatment of depression

Mental Health Carve-Outs: Effects and Implications

To control the rise in expenditures and to increase access to mental health and substance abuse (MH/SA) services, a growing number of employers and states are implementing a “carve-out.” Under this arrangement, the sponsor separates insurance benefits by disease or condition, service category, or population and contracts separately for the management of care and/or associated risks. A carve-out allows a unique set of managed care techniques to be applied to a subset of particularly costly or complex benefits. This article describes various carve-out models, discusses the potential advantages and disadvantages of a full carve-out, and summarizes recent public and private sector research regarding the strategy’s effects on access and use, cost savings and shifting, and quality of care. It concludes by discussing approaches to the assessment and monitoring of the processes and outcomes associated with a MH/SA carve-out.

Young adults with depression are at increased risk of sexually transmitted disease

Sexually transmitted diseases (STDs) and depression impact millions of individuals each year in the United States, with direct medical costs exceeding $41 billion. While the interactions of these conditions are poorly understood, they are increasingly addressed in primary care whereas historically they have been addressed separately. We analyzed data associated with the 18-25year age group from the 2014 National Survey of Drug Use and Health, a cross-sectional survey of the civilian, non-institutionalized US population aged ≥12years for factors associated with past year diagnosis of STD (STDy). Independent variables included participant demographics; lifetime diagnosis of major depressive episode (MDE); participant behaviors associated with STD risk (patient-provided); and medical record data associated with mental illness treatment (clinically-observed). Of 18,142 participants, the prevalence of MDE and STD was 15.3% and 2.4%, respectively, with significant differences by gender and race. MDE was associated with increased risk of STDy among females (odds ratio [OR]=1.61; 95% confidence interval [CI]=1.18-2.20), males (OR=2.32; CI=1.15-4.70), those of white race (OR=3.02; CI=2.02-4.53), and lower income levels and insurance status. Univariate modeling found that receiving mental health treatment, and use of marijuana, alcohol, and illegal drugs were each associated with significantly increased STDy. In a multivariate logistic regression, receiving mental health treatment became protective for STDy (AOR=0.55; CI=0.32-0.95]). Individuals with a history of depression are at increased risk of STDy, with this risk modified by factors readily ascertained within primary care. As depression treatment is increasingly incorporated into primary care there are means to more effectively target intervention resources.

Adult depression screening in Saudi primary care: prevalence, instrument and cost

BACKGROUND

By the year 2020 depression would be the second major cause of disability adjusted life years lost, as reported by the World Health Organization. Depression is a mental illness which causes persistent low mood, a sense of despair, and has multiple risk factors. Its prevalence in primary care varies between 15.3-22%, with global prevalence up to 13% and between 17-46% in Saudi Arabia. Despite several studies that have shown benefit of early diagnosis and cost-savings of up to 80%, physicians in primary care setting continue to miss out on 30-50% of depressed patients in their practices.

METHODS

A cross sectional study was conducted at three large primary care centers in Riyadh, Saudi Arabia aiming at estimating point prevalence of depression and screening cost among primary care adult patients, and comparing Patient Health Questionnaires PHQ-2 with PHQ-9. Adult individuals were screened using Arabic version of PHQ-2 and PHQ-9. PHQ-2 scores were correlated with PHQ-9 scores using linear regression. A limited cost-analysis and cost saving estimates of depression screening was done using the Human Capital approach.

RESULTS

Patients included in the survey analysis were 477, of whom 66.2% were females, 77.4% were married, and nearly 20% were illiterate. Patients exhibiting depressive symptoms on the basis of PHQ9 were 49.9%, of which 31% were mild, 13.4% moderate, 4.4% moderate-severe and 1.0% severe cases. Depression scores were significantly associated with female gender (p-value 0.049), and higher educational level (p-value 0.002). Regression analysis showed that PHQ-2 & PHQ-9 were strongly correlated R = 0.79, and R2 = 0.62. The cost-analysis showed savings of up to 500 SAR ($133) per adult patient screened once a year.

CONCLUSION

The point prevalence of screened depression is high in primary care visitors in Saudi Arabia. Gender and higher level of education were found to be significantly associated with screened depression. Majority of cases were mild to moderate, PHQ-2 was equivocal to PHQ 9 in utility and that screening for depression in primary care setting is cost saving.

Do HIV-positive women receive depression treatment that meets best practice guidelines?

This study addressed whether psychopharmacologic and psychotherapeutic treatment of depressed HIV+ women met standards defined in the best practice literature, and tested hypothesized predictors of standard-concordant care. 1,352 HIV-positive women in the multi-center Women's Interagency HIV Study were queried about depressive symptoms and mental health service utilization using standards published by the American Psychiatric Association and the Agency for Healthcare Research and Quality to define adequate depression treatment. We identified those who: (1) reported clinically significant depressive symptoms (CSDS) using Centers for Epidemiological Studies-Depression Scale scores of ≥16; or (2) had lifetime diagnoses of major depressive disorder (MDD) assessed by World Mental Health Composite International Diagnostic Interviews plus concurrent elevated depressive symptoms in the past 12 months. Adequate treatment prevalence was 46.2 % (n = 84) for MDD and 37.9 % (n = 211) for CSDS. Multivariable logistic regression analysis found that adequate treatment was more likely among women who saw the same primary care provider consistently, who had poorer self-rated role functioning, who paid out-of-pocket for healthcare, and who were not African American or Hispanic/Latina. This suggests that adequate depression treatment may be increased by promoting healthcare provider continuity, outreaching individuals with lower levels of reported role impairment, and addressing the specific needs and concerns of African American and Hispanic/Latina women.

The effect of comprehensive behavioral health parity on choice of provider

BACKGROUND

"Parity" laws remove treatment limitations for mental health and substance-abuse services covered by commercial health plans. A number of studies of parity implementations have suggested that parity does not lead to large increases in utilization or expenditures for behavioral health services. However, less is known about how parity might affect changes in patients' choice of providers for behavioral health treatment.

RESEARCH DESIGN

We compared initiation and provider choice among 46,470 Oregonians who were affected by Oregon's 2007 parity law. Oregon is the only state to have enacted a parity law that places restrictions on how plans manage behavioral health services. This approach has been adopted federally in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. In 1 set of analyses, we assess initiation and provider choice using a difference-in-difference approach, with a matched group of commercially insured Oregonians who were exempt from parity. In a second set of analyses, we assess the impact of distance on provider choice.

RESULTS

Overall, parity in Oregon was associated with a slight increase (0.5% to 0.8%) in initiations with masters-level specialists, and relatively little changes for generalist physicians, psychiatrists, and psychologists. Patients are particularly sensitive to distance for nonphysician specialists.

CONCLUSIONS

Our results suggest that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act may lead to a shift in the use of nonphysician specialists and away from generalist physicians. The extent to which these changes occur is likely to be contingent on the ease and accessibility of nonphysician specialists.

A nationwide prospective study on prescribing pattern of antidepressant drugs in Italian primary care

PURPOSE

Our purpose was to explore antidepressant drug (AD) prescribing patterns in Italian primary care.

METHODS

Overall, 276 Italian general practitioners (GPs) participated in this prospective study, recruiting patients >18 years who started AD therapy during the enrolment period (January 2007 to June 2008). During visits at baseline and 3, 6, and 12 months, data about patients' characteristics and AD treatments were collected by the GPs. Discontinuation rate among new users of AD classes [i.e., selective serotonin reuptake inhibitors (SSRI); tricyclics (TCAs); other ADs) were compared. Logistic regression analyses were performed to identify predictors of AD discontinuation.

RESULTS

SSRIs were the most frequently prescribed ADs (N = 1,037; 75.3 %), especially paroxetine and escitalopram. SSRIs were more likely to be prescribed because of depressive disorders (80 %), and by GPs (51.1 %) rather than psychiatrists (31.8 %). Overall, 27.5 % (N = 378) of AD users discontinued therapy during the first year, mostly in the first 3 months (N = 242; 17.6 %), whereas 185 (13.4 %) were lost to follow-up. SSRI users showed the highest discontinuation rate (29 %). In patients with depressive disorders, younger age, psychiatrist-based diagnosis, and treatment started by GPs were independent predictors of SSRI discontinuation.

CONCLUSIONS

In Italy, ADs-especially SSRIs-are widely prescribed by GPs because of depressive/anxiety disorders. Active monitoring of AD users in general practice might reduce the AD discontinuation rate.

The impact of financial incentives on physician empathy: a study from the perspective of patients with private and statutory health insurance

OBJECTIVE

We hypothesized that patients' ratings of physician empathy (PE) would be higher among those with private health insurance (PHI, referring to financial incentive) than among patients with statutory health insurance (SHI).

METHODS

A postal survey was administered to 710 cancer patients. PE was assessed using the Consultation-and-Relational-Empathy measure. T-tests were conducted to analyse whether PHI and SHI-patients differ in their ratings of PE and variables relating to contact time with the physician. Structural-equation-modelling (SEM) verified mediating effects.

RESULTS

PHI-patients rated physician empathy higher. SEM revealed that PHI-status has a strong significant effect on frequency of talking with the physician, which has a strong significant effect (1) on PE and (2) has a moderate effect on patients' perception of medical staff stress, thereby also affecting patients' ratings of PE.

CONCLUSIONS

Our findings suggest that PHI-status is one necessary precondition for physicians spending more time with the patient. Spending more time with the PHI-patient has two major effects: it results in a more positive perception of PE and positively impacts PHI-patients' perception of medical staff stress, which in turn, again influences PE.

PRACTICAL IMPLICATIONS

Health policy should discuss these findings in terms of equality in receiving high-quality care.

Determining factors in the treatment choice of patients with hypertension with complications and secondary hypertension

PURPOSE

The purpose of this article is to analyze the effects patients' socioeconomic characteristics, along with hospital size and location, had on the initial treatment choice for individuals with hypertension with complications and secondary hypertension.

DESIGN/METHOD/APPROACH

The analysis uses retrospective data and binary logistic regression to analyze treatment choice determinants. Initial diagnostic and/or therapeutic procedures were categorized as invasive or non-invasive, which served as the dependent variable.

FINDINGS

Uninsured people were more likely to get less expensive non-invasive treatment. Medicare patients were approximately twice as likely to receive an invasive procedure as individuals with private insurance, even after controlling for age and other socioeconomic characteristics. Minorities and males were also more likely to receive an invasive primary procedure. Significant treatment variations across States were also found.

RESEARCH LIMITATIONS/IMPLICATIONS

There were insufficient observations to look at variability within patients treated by a single physician. Future research could tie this information into a simultaneous equation system in order to determine whether patients who received one treatment type versus another were better off.

PRACTICAL IMPLICATIONS

Finding that characteristics other than morbidity affect the type of treatment received indicates that public policy could improve care. Most important, the ability to pay, type of insurance, geographic location and race influence whether patients receive invasive or non-invasive treatment upon hospitalization for hypertension, indicating that policies prescribing treatment alternatives that remove non-medical issues from calculation may improve overall outcomes.

ORIGINALITY/VALUE

Comprehensive treatment-choice analyzes have been largely overlooked in the hypertension literature. Additionally, few studies analyze choice using data from such a diverse array of geographic areas and socio-economic strata.

Current Status and Future Prospects of Clinical Psychology: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care

The escalating costs of health care and other recent trends have made health care decisions of great societal import, with decision-making responsibility often being transferred from practitioners to health economists, health plans, and insurers. Health care decision making increasingly is guided by evidence that a treatment is efficacious, effective-disseminable, cost-effective, and scientifically plausible. Under these conditions of heightened cost concerns and institutional-economic decision making, psychologists are losing the opportunity to play a leadership role in mental and behavioral health care: Other types of practitioners are providing an increasing proportion of delivered treatment, and the use of psychiatric medication has increased dramatically relative to the provision of psychological interventions. Research has shown that numerous psychological interventions are efficacious, effective, and cost-effective. However, these interventions are used infrequently with patients who would benefit from them, in part because clinical psychologists have not made a convincing case for the use of these interventions (e.g., by supplying the data that decision makers need to support implementation of such interventions) and because clinical psychologists do not themselves use these interventions even when given the opportunity to do so. Clinical psychologists' failure to achieve a more significant impact on clinical and public health may be traced to their deep ambivalence about the role of science and their lack of adequate science training, which leads them to value personal clinical experience over research evidence, use assessment practices that have dubious psychometric support, and not use the interventions for which there is the strongest evidence of efficacy. Clinical psychology resembles medicine at a point in its history when practitioners were operating in a largely prescientific manner. Prior to the scientific reform of medicine in the early 1900s, physicians typically shared the attitudes of many of today's clinical psychologists, such as valuing personal experience over scientific research. Medicine was reformed, in large part, by a principled effort by the American Medical Association to increase the science base of medical school education. Substantial evidence shows that many clinical psychology doctoral training programs, especially PsyD and for-profit programs, do not uphold high standards for graduate admission, have high student-faculty ratios, deemphasize science in their training, and produce students who fail to apply or generate scientific knowledge. A promising strategy for improving the quality and clinical and public health impact of clinical psychology is through a new accreditation system that demands high-quality science training as a central feature of doctoral training in clinical psychology. Just as strengthening training standards in medicine markedly enhanced the quality of health care, improved training standards in clinical psychology will enhance health and mental health care. Such a system will (a) allow the public and employers to identify scientifically trained psychologists; (b) stigmatize ascientific training programs and practitioners; (c) produce aspirational effects, thereby enhancing training quality generally; and (d) help accredited programs improve their training in the application and generation of science. These effects should enhance the generation, application, and dissemination of experimentally supported interventions, thereby improving clinical and public health. Experimentally based treatments not only are highly effective but also are cost-effective relative to other interventions; therefore, they could help control spiraling health care costs. The new Psychological Clinical Science Accreditation System (PCSAS) is intended to accredit clinical psychology training programs that offer high-quality science-centered education and training, producing graduates who are successful in generating and applying scientific knowledge. Psychologists, universities, and other stakeholders should vigorously support this new accreditation system as the surest route to a scientifically principled clinical psychology that can powerfully benefit clinical and public health.

Expanded mental health benefits and outpatient depression treatment intensity

BACKGROUND

The justification for higher cost-sharing for behavioral health treatment is its greater price sensitivity relative to general healthcare treatment. Despite this, recent policy efforts have focused on improving access to behavioral health treatment.

OBJECTIVES

We measured the effects on outpatient treatment of depression of a change in mental health benefits for employees of a large U.S.-based corporation.

RESEARCH DESIGN

The benefit change involved 3 major elements: reduced copayments for mental health treatment, the implementation of a selective contracting network, and an effort to destigmatize mental illness. Claims data and a difference-in-differences methodology were used to examine how the benefit change affected outpatient treatment of depression.

SUBJECTS

Subjects consisted of 214,517 employee-years of data for individuals who were continuously enrolled for at least 1 full year at the intervention company and 96,365 employee-years in the control group.

MEASURES

We measured initiation into treatment of depression and the number of outpatient therapy visits.

RESULTS

The benefit change was associated with a 26% increase in the probability of initiating depression treatment. Conditional on initiating treatment, patients in the intervention company received 1.2 additional (P < 0.001) outpatient mental health treatment visits relative to the control group.

CONCLUSIONS

Our results suggest that the overall effect of the company's benefit change was to significantly increase the number of outpatient visits per episode of treatment conditional on treatment initiation.

The effect of expanded mental health benefits on treatment initiation and specialist utilization

OBJECTIVE

To measure the effects of a mental health benefit design change on treatment initiation for psychiatric disorders of employees of a large U.S.-based company.

DATA SOURCES

Mental health treatment administrative claims data plus eligibility information provided by the company for the years 1995-1998.

STUDY DESIGN

We measure the effect of a change in mental health benefits consisting of three major elements: a company-wide effort to destigmatize mental illness; reduced copayments for mental health treatment; and an effort to increase access to specialty mental health providers.

DATA EXTRACTION METHODS

We identified the subsample of employees that were continuously enrolled in the company's health plan over the period 1995-1998, were between the ages of 18 and 65, and were actively employed.

PRINCIPAL FINDINGS

Our results suggest that the combined effect of destigmatization and reduced copayments led to an 18 percent increase (p<.01) in the probability of initiating mental health treatment. The results suggest that the effort to increase access to specialty providers was effective, but only for nonphysician providers: initiation at nonphysician mental health providers increased nearly 90 percent (p<.01) relative to nonspecialty providers, while use of psychiatrists declined by nearly 40 percent (p<.01).

CONCLUSIONS

Our results suggest that the benefit change increased initiation for mental health treatment overall and encouraged the use of nonphysician specialty mental health providers.

Trends in elderly patients' office visits for the treatment of depression according to physician specialty: 1985-1999

Changes from 1985 to 1999 in diagnosis of depression and prescription of antidepressant medications during visits by elderly patients to primary care physicians, psychiatrists, and other specialists were examined. Using nationally representative surveys of office-based practices, estimates of the proportion of office visits by elderly patients during which a physician diagnosed depression or prescribed an antidepressant medication were obtained. Between 1985 and 1993-1994, a significant increase in the rate of depression diagnosis was seen, but no change was observed between 1993-1994 and 1998-1999. Rates of prescribing of antidepressants more than doubled between 1985 and 1998-1999. The majority of depression visits and visits where an antidepressant was prescribed were to primary care physicians in all time periods examined. Primary care depression treatment initiatives should place greater emphasis on elderly patients.

Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms

OBJECTIVE

To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms.

DESIGN

Prospective cohort study.

SETTING

Offices of 261 primary physicians in private practice in Seattle.

PATIENTS

Patients (N = 17,187) were screened in waiting rooms, enrolling 1,336 adults with depressive symptoms. Patients (n = 942) completed follow-up surveys at 1, 3, and 6 months.

MEASUREMENTS AND RESULTS

For each patient, the intensity of managed care was measured by the managedness of the patient's health plan, plan benefit indexes, presence or absence of a mental health carve-out, intensity of managed care in the patient's primary care office, physician financial incentives, and whether the physician read or used depression guidelines. Access measures were referral and actually seeing a mental health specialist. Outcomes were the Symptom Checklist for Depression, restricted activity days, and patient rating of care from primary physician. Approximately 23% of patients were referred to mental health specialists, and 38% saw a mental health specialist with or without referral. Managed care generally was not associated with a reduced likelihood of referral or seeing a mental health specialist. Patients in more-managed plans were less likely to be referred to a psychiatrist. Among low-income patients, a physician financial withhold for referral was associated with fewer mental health referrals. A physician productivity bonus was associated with greater access to mental health specialists. Depressive symptom and restricted activity day outcomes in more-managed health plans and offices were similar to or better than less-managed settings. Patients in more-managed offices had lower ratings of care from their primary physicians.

CONCLUSIONS

The intensity of managed care was generally not associated with access to mental health specialists. The small number of managed care strategies associated with reduced access were offset by other strategies associated with increased access. Consequently, no adverse health outcomes were detected, but lower patient ratings of care provided by their primary physicians were found.

Effects of cost-containment strategies within managed care on continuity of the relationship between patients with depression and their primary care providers

BACKGROUND

Continuity of the relationship between patients and primary care providers (PCPs) is an important component of care from the consumer perspective that may be affected by variation in cost containment strategies within managed care.

OBJECTIVE

To evaluate the effects of cost containment strategies on the continuity of the relationship between their patients with depression and their PCPs.

DESIGN

Observational analysis of a 2-year panel of depressed patients who participated in a quality improvement intervention trial in 46 managed care practices.

PARTICIPANTS

One thousand two hundred four patients with current depression who enrolled in a longitudinal study, completed the baseline survey, and were followed for 2 years.

MAIN MEASURES

The dependent variable is probability of continuing the relationship between patients and their PCPs; explanatory variables include individual patient mental health benefits and cost-sharing, individual provider financial incentives, supply-side managed care policies, and patient ratings of the care received.

RESULTS

The average duration of the patient-PCP relationship was significantly longer among depressed patients who initially had less generous benefits for specialty care (higher copays, P = 0.02 and fewer visits covered, P = 0.002) and for patients whose PCPs received a performance-based salary bonus from a risk pool (P = 0.07).

CONCLUSIONS

For depressed patients, cost containment strategies, such as limits on specialty benefits and presence of clinician bonus payments typically used within managed care may increase, rather than decrease, PCP continuity. Whether increased PCP continuity is a desirable outcome depends on whether health care systems can provide high quality primary care and this merits further study.

Continuity of care: a reconceptualization

Although continuity of care is considered an essential feature of good health care, researchers have used and measured continuity in many different ways, and no clear conceptual framework links continuity to outcomes. This article of offers a reconceptualization and definition of continuity based on agency theory. It posits that the value of continuity is to reduce agency loss by decreasing information asymmetry and increasing goal alignment. Three decades of empirical literature on continuity were examined to assess whether this model would provide greater clarity about continuity. Some authors measured improved information transfer, but more appeared to assume that continuity would lead to better information. Most authors appeared to have assumed that goal alignment was present and did not measure it. The model of continuity based on agency theory appears to provide a useful conceptual tool for health services research and policy.

Are better ratings of the patient-provider relationship associated with higher quality care for depression?

BACKGROUND

The interpersonal patient-provider relationship (PPR) is an essential part of health care quality, particularly for patients with depression, yet little is known neither about how to measure this relationship nor about its association with quality of care.

OBJECTIVES

To evaluate properties of patient rating measures, understand the relation between 2 types of ratings, and determine the association of ratings with quality depression care.

SETTING AND PARTICIPANTS

1,104 patients with current depressive symptoms and lifetime or 12-month disorder identified through screening 27,332 consecutive primary care visitors in 6 managed care organizations participating in Partners in Care (PIC).

DESIGN

Cross-sectional analysis of 18-month data (collected in 1998) after the start of PIC depression quality improvement (QI) interventions (in which clinics were randomized to 1 of 2 QI interventions or usual care).

MEASURES

Patient ratings of the interpersonal relationship with the primary care provider and satisfaction with health care, and quality of depression care indicators.

ANALYSIS

Factor analysis and multitrait scaling to evaluate the psychometric properties of multiitem constructs and analysis of covariance to evaluate associations between patient ratings and quality.

RESULTS

Patient ratings had high internal consistency and met criteria for discriminant validity tapping unique aspects of care. Patients receiving quality care, especially for medication use, had significantly higher ratings of the interpersonal relationship (by 22% to 27% of a SD) and were more satisfied (by 26% to 34% of a SD) than patients who did not receive quality care.

CONCLUSIONS

Ratings of the interpersonal relationship and satisfaction measure distinct aspects of care and are positively associated with quality care for depression.

Provider choice and utility loss due to selective contracting in rural and urban areas

An econometric model estimated the disutility of traveling long distances for depression treatment, and simulations calculated the utility loss associated with selective contracting in rural and urban areas. A representative sample of depression patients (n = 106) and all practicing providers (n = 3,710) in Arkansas were identified and the distances between them were calculated. Using discrete choice analysis, patient preferences for provider type and travel distance were estimated. Simulations calculated the utility loss associated with alternative scenarios of selective contracting. Provider type and distance were significant predictors of provider choice. To equate the utility loss associated with selective contracting in rural and urban areas, a slightly higher proportion of rural physicians and a substantially higher proportion of rural mental health specialists must be contracted. To avoid further reductions in geographic access, managed care organizations should contract with a higher proportion of rural providers than urban providers.

General medical and specialty mental health service use for major depression

OBJECTIVE

While major depression is common, many depressed persons receive, at best, inadequate treatment. A first step in remedying inadequate detection and treatment of major depression requires understanding the pathways into treatment-from situations of no care, to disease recognition, to referral and appropriate treatment-as well as identifying factors associated with movement between these several stages.

METHODS

Using the Epidemiologic Catchment Area sample, we identified factors associated with treatment in the general medical or mental health specialist section, or no treatment in a subsample of individuals with current major depression.

RESULTS

Strikingly, one-fourth of the sample received no services, over half received care in the general medical sector, and only one-fifth accessed a mental health specialist. Among those receiving any health services (general or mental), men and respondents reporting suicidal symptoms were at risk of receiving no care, while perceived poor health and a cluster of core depressive symptoms were associated with increased odds of service use (general or mental). Among respondents receiving general medical services, perceived poor health, core depressive symptoms, a history of depression, and comorbid mental conditions increased the odds of treatment in the specialty mental health sector.

CONCLUSIONS

The findings emphasize the need for public health initiatives to 1) improve detection and movement into treatment among those at risk of receiving no care; and 2) insure that, once within the health care system, the processes of primary care treatment and specialty referrals conform to evidence-based treatment guidelines.

The impact of prior authorization on outpatient utilization in managed behavioral health plans

This study examines how preauthorization affects outpatient behavioral health utilization under managed care by comparing plans with similar benefits, but differing in the number of visits authorized. The authors compare plans primarily authorizing in increments of 5 visits to plans authorizing in increments of 10 visits. They analyze the likelihood of terminating outpatient service between the two groups using conditional logistic regression. Results suggest that patients whose treatment is authorized in increments of 5 sessions are nearly 3 times more likely to terminate treatment at exactly the fifth visit than if their treatment is authorized in increments of 10 sessions conditional on being in treatment until the 5th visit. The likelihood of termination peaks in both the 5- and 10-session authorization at the 10th visit, but the difference is not statistically significant. The authorization effect differs by provider type and is weaker among psychiatrists than among nonphysician providers.

A systems perspective on research and treatment with abused and neglected children

OBJECTIVE

To discuss two systems-level changes in the organization and financing of mental health and child welfare services that will increasingly affect abused and neglected children: the implementation of managed care processes and the incorporation of accountability mechanisms in the management of mental health and child welfare services, particularly the use of systematic outcomes assessments. A central goal of the paper is to identify critical research questions which will help us to understand the impact of these changes on maltreated children.

METHOD

These two systems-level changes are described, and ways they may affect maltreated children are addressed.

RESULTS

Both managed care and the growing focus on managing services by monitoring outcomes may positively or negatively affect maltreated children. Both of these trends are affecting the mental health and child welfare systems. It is likely that they will affect maltreated children's access to and the quality, cost, and outcomes of mental health and child welfare services.

CONCLUSIONS

Systematic research on the impact of these large-scale changes can increase the likelihood that these changes will benefit maltreated children. A number of critical areas are identified for future research.

Primary care in the United States and its precarious future

Primary care has not secured a firm place within the US health services system. Since primary care lacks a strong research base, is not institutionalized in medical education or in policy-making and is marginalized in both proposed and actual reforms, it has not developed into a central component of the health care infrastructure. We discuss recent efforts that promised modest improvements, including the Clinton health care reform proposals and subsequent federal and state actions, in the role of primary care within the health services system. We also assess the likely fate of primary care given the accelerated growth of managed care and market competition, the dissatisfaction of large segments of the population with managed care and misperceptions of managed care as synonymous with primary care. We highlight how managed care fails to achieve the cardinal functions of primary care and summarize initiatives that, at a minimum, would be required to secure a stronger position for primary care in the future.

The influence of gatekeeping and utilization review on patient satisfaction

OBJECTIVE

To examine the influence of utilization review and denial of specialty referrals on patient satisfaction with overall medical care, willingness to recommend one's physician group to a friend, and desire to disenroll from the health plan.

DESIGN

Two cross-sectional questionnaires: one of physician groups and one of patient satisfaction.

SETTING

Eighty-eight capitated physician groups in California.

PARTICIPANTS

Participants were 11,710 patients enrolled in a large California network-model HMO in 1993 who received care in one of the 88 physician groups.

MEASUREMENTS AND MAIN RESULTS

Our main measures were how groups conducted utilization review for specialty referrals and tests, patient-reported denial of specialty referrals, and patient satisfaction with overall medical care. Patients in groups that required preauthorization for access to many types of specialists were significantly (p

CONCLUSIONS

Policies that limited direct access to specialists, and especially denial of patient-desired referrals, were associated with significantly lower patient satisfaction, increased desire to disenroll, and lower likelihood of recommending the group to a friend. Health plans and physician groups need to take these factors into account when designing strategies to reduce specialty care use.

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Key Words

• patient satisfaction
• access to specialists
• gatekeeping
• utilization management
• managed care

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MESH Headings

• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Cross-Sectional Studies
• Female
• Health Services Needs and Demand
• Humans
• Linear Models
• Male
• Managed Care Programs/standards
• Middle Aged
• Multivariate Analysis
• Outcome Assessment, Health Care
• Patient Satisfaction/statistics & numerical data
• Policy Making
• Referral and Consultation/statistics & numerical data
• Reproducibility of Results
• Surveys and Questionnaires
• United States
• Utilization Review/statistics & numerical data

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Affiliation(s)

E A Kerr Center for Practice Management and Outcomes Research, VA Medical Center, Ann Arbor, Mich., USA
R D Hays
A Mitchinson
M Lee
A L Siu

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Treatment of depression in older primary care patients in health maintenance organizations

OBJECTIVE

To examine whether older HMO patients with depression are treated differently than younger patients in terms of diagnosis, treatment by specialty provider, and pharmacotherapy.

DESIGN

Chart-review, Cross sectional study.

SETTING AND PARTICIPANTS

Patients were selected from six HMOs in the United States who had one or more of five medical diagnoses: arthritis, asthma, otitis media, epigastric pain/ulcer, and hypertension, (n = 9143). From this group, chart diagnoses and pharmacy records were used to identify patients who also had a diagnosis of depression (n = 416) or who had a diagnosis of depression and/or treatment with antidepressant medication (n = 1286).

MEASUREMENT

Medical records and computerized service and pharmacy records were reviewed to obtain diagnoses, office visits by provider type, and psychiatric medication prescription counts.

RESULTS

Significant differences were found in treatment of depression for older versus younger patients. Although depression was identified at a similar rate for both groups, older patients received fewer mental health specialty visits and fewer prescriptions for SSRI antidepressants. Older patients with a diagnosis of depression were more likely to be treated with benzodiazepines (49.2% of older vs. 33.2% of younger) though they were less likely to receive long half-life benzodiazepines.

CONCLUSIONS

Psychotropic medication management is an important target for improving quality of care for older patients with depression in HMOs. Decreasing inefficient minor tranquilizer use and increasing use of newer antidepressant medications may lead to improved outcomes for older depressed adults.

The future of primary care in a managed care era

Health care reform in the United States and elsewhere raises many questions about equity and effectiveness of health services. Although the impetus has been cost containment, the reforms have often been justified on the grounds that they will enhance primary care. In this article, health care reform efforts are divided into two types: market-driven, demand-based systems versus systems predicated on meeting population health needs. The two "scenarios" are contrasted with regard to their likely impact on the attainment of primary care characteristics: first-contact care, longitudinality, comprehensive services, and coordination. Since the ultimate outcome of these reforms cannot be predicted, there is compelling need for evaluating them as they proceed.

Does managed care lead to better or worse quality of care?

We analyzed evidence on managed care plan (mostly health maintenance organization, or HMO) performance from thirty-seven recently published peer-reviewed studies. Quality-of-care evidence from fifteen studies showed an equal number of significantly better and worse HMO results, compared with non-HMO plans. However, in several instances, Medicare HMO enrollees with chronic conditions showed worse quality of care. Evidence comparing hospital and physician resource use showed no clear pattern, whereas evidence on enrollee satisfaction varied by measure and enrollee type. Although recent research provides useful findings, interpreting and generalizing from these relatively few studies is difficult. Fears that HMOs uniformly lead to worse quality of care are not supported by the evidence, although all quality data were collected prior to the recent round of cost cutting that started in 1992. Hopes that HMOs would improve overall quality also are not supported, in part because of slow clinical practice change, lack of risk-adjusted capitation rates, and inadequate quality measurement and reporting.

Measuring health outcomes for depression

In this article, we describe the clinical and health-related quality of life outcome measures for depressed patients in the Medical Outcomes Study, a 4-year longitudinal study that started in 1986. We prioritize the measures in terms of importance, consider how they can be improved in future studies, and discuss how they should be used in more applied evaluations, such as studies by managed care companies and group practices. We emphasize the importance of identifying appropriate evaluation questions and selecting study designs and patient populations that permit meaningful answers about evaluating outcomes of care for depression. Although the outcome measures described here may be a useful starting point, they will need to be combined with carefully constructed measures of process of care as well, so that links between the two can be maximized.