Use of outpatient mental health services over time in a health maintenance organization and fee-for-service plans

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.

Conceptions of authority within contemporary social work practice in managed mental health care organizations

This article examines how social workers may use their authority to create managed mental health care organizations that support the principles and values of professional social work practice. By exploring research and theoretical contributions from a multidisciplinary perspective, the author suggests ways that social workers may incorporate empowerment strategies into their organizational practices to create more socially responsible and humane mental health organizations.

Children's use of mental health services in different Medicaid insurance plans

This study examined the effect of different Medicaid insurance plans on children's mental health service use through survey, claims, and encounter data collected between February 1998 and February 1999. Participants were assigned to 1 of 3 insurance plans: fee-for-service, a Health Maintenance Organization and a prepaid carve-out. Logistic and stratified logistic regression were used to examine the effect of plan on service utilization, adjusting for caregiver report of need for services and psychosocial functioning. There was no difference in service use by plan controlling for demographic characteristics; however, when psychopathology and caregiver report of need for services were included in the model, the odds of using services in the Health Maintenance Organization was half of and the odds in the carve-out 29% less than the odds of using services in fee-for-service. Characteristics of the interaction between need, psychopathology, and insurance plan that may be associated with the reduction in service use are discussed.

Alcohol, drug abuse, and mental health care for uninsured and insured adults

OBJECTIVE

To compare adults with different insurance coverage in care for alcohol, drug abuse, and mental health (ADM) problems.

DATA SOURCES/STUDY SETTING

From a national telephone survey of 9,585 respondents.

DESIGN

Follow-up of adult participants in the Community Tracking Study.

DATA COLLECTION

Self-report survey of insurance plan (Medicare, Medicaid, unmanaged, fully, or partially managed private, or uninsured), ADM need, use of ADM services and treatments, and satisfaction with care in the last 12 months. PRINCIPAL METHODS: Logistic and linear regressions were used to compare persons by insurance type in ADM use.

PRINCIPAL FINDINGS

The likelihood of ADM care was highest under Medicaid and lowest for the uninsured and those under Medicare. Perceived unmet need was highest for the uninsured and lowest under Medicare. Persons in fully rather than partially managed private plans tend to be more likely to have ADM care and ADM treatments given need. Satisfaction with care was high in public plans and low for the uninsured.

CONCLUSIONS

The uninsured have the most problems with access to and quality of ADM care, relative to the somewhat comparable Medicaid population. Persons in fully managed plans had better rather than worse access and quality compared to partially managed plans, but findings are exploratory. Despite low ADM use, those with Medicare tend to be satisfied. Across plans, unmet need for ADM care was high, suggesting changes are needed in policy and practice.

Affective disorders in children and adolescents: addressing unmet need in primary care settings

Affective disorders are common among children and adolescents but may often remain untreated. Primary care providers could help fill this gap because most children have primary care. Yet rates of detection and treatment for mental disorders generally are low in general health settings, owing to multiple child and family, clinician, practice, and healthcare system factors. Potential solutions may involve 1) more systematic implementation of programs that offer coverage for uninsured children; 2) tougher parity laws that offer equity in defined benefits and application of managed care strategies across physical and mental disorders; and 3) widespread implementation of quality improvement programs within primary care settings that enhance specialty/primary care collaboration, support use of care managers to coordinate care, and provide clinician training in clinically and developmentally appropriate principles of care for affective disorders. Research is needed to support development of these solutions and evaluation of their impacts.

Managed care and its implications for social work curricula reform: policy and research initiatives

A multitude of social, economic, and health factors are forcing the health care industry to examine the effectiveness and efficiency of health and mental health care delivery. Managed care has emerged in this environment of cost containment, as a viable distributive mechanism for the allocation of health care resources. Schools of social work must consider additions and/or revisions to their curriculum, in order to adequately prepare social workers to practice in a managed care environment. A major barrier is the negative attitude held by many practitioners and educators towards managed care. This paper discusses the evolution of managed care, and the challenges to social work education, including the necessity for developing a more balanced view of managed care. Suggested curricular revisions are provided for two major content areas: policy and research.

Quality and customers: a planning approach to the future of mental health services in a health maintenance organization

Mental health service delivery is both a health care and business arrangement, and is accordingly impacted by national changes in both areas. HMO mental health services in the current health reform zeitgeist are being called on to provide more efficient, comprehensive integrated care. A planning effort is presented which is organized around (1) a quality improvement effort aimed at understanding who are the "customers" (patient, medical community, mental health staff, and client employer) and what they need and (2) coordination and integration with the HMO larger organizational plan and efforts. The unique benefits of staff model HMOs are discussed relative to mental health service.

Technologies for the delivery of mental health care

Mental health services depend both on efficacious drug and interpersonal interventions and strategies for financing, organizing, and delivering these services. In recent years, much attention has been devoted to approaches that seek to coordinate needed care and to provide it in the most cost-effective ways. Cost constraints encourage the substitution of alternative community treatments for expensive inpatient care and the identification of appropriate ways to link effectively the varying care components. The mechanism most commonly advocated is case management, but the concept is applied in diverse ways and has little agreed upon meaning and disparate outcomes. This paper discusses and evaluates concepts of case management and a variety of other systems interventions designed to reduce fragmentation. It also reviews approaches to managed care, including mental health capitation and utilization management. New organizational technologies are likely to change dramatically professional practices and standards and the future provision of mental health care.

Health care utilization for emotional problems: results from a community survey

A survey was conducted in which 865 randomly selected adult household residents of Edmonton, Alberta were interviewed to obtain information about health care in the preceding year. Eighty percent of the sample had seen a family physician, and eight percent of visits to family physicians involved a mental or emotional problem. Thirteen percent of the sample received professional help for a mental or emotional problem from some type of caregiver. The most frequently consulted professional was the family physician (eight percent of the sample), followed by psychologists and psychiatrists (each seeing two percent of the sample). Family physicians accounted for the greatest number of consultations for mental or emotional problems (41%), followed by psychologists (16%), social workers (12%) and psychiatrists (nine percent). Women were 27% more likely to seek a consultation than men, and consultation rates were highest in the group ranging in age from 35 to 44 years. There was also a strong relationship between having recent psychiatric symptoms and having had a consultation in the past year.