A survey of state insurance mandates covering alcohol and other drug treatment

This article reports the results of a survey of health insurance mandate legislation for alcohol and other drug treatment in the 50 states through spring 1991. A total of 23 states (including the District of Columbia) requires insurance carriers to provide coverage for alcohol and other drug treatment. This paper compares the provisions in these states at the present time and contrasts these provisions with those in effect in 1981. The paper concludes with a discussion of the policy objectives states pursue through enactment of such legislation and the outcomes brought about by the mandates.

Psychiatric hospital care and changes in insurance coverage strategies: a national study

The 1975, 1980, and 1986 sample surveys from the National Institute of Mental Health were used to predict the type of inpatient psychiatric facility where people were admitted. Predictors used were demographics (age, gender, race, marital status, and education), psychiatric diagnosis, and insurance status (primary payment source). A discriminant analysis revealed that insurance status was the most important discriminator in predicting hospital type. State hospitals were more likely to care for patients with little or no resources, whereas private hospitals cared for patients with some form of insurance. The authors discuss the implications of insurance status and access to psychiatric treatment.

Private sector coverage of people with dual diagnoses

In general, people with dual diagnoses account for a significant proportion of both the mental health and substance abuse populations. Most published information on dual diagnosis comes from research on selected treatment programs that are largely funded from public sources. This analysis uses private health insurance claims and eligibility files for 1989 to 1991 for three large firms to identify individuals with both substance abuse and mental health claims and to examine their characteristics, charges, and utilization. More than half of people with dual diagnoses incurred significant charges over three years in both mental health and substance abuse. These individuals with high mental health charges were more likely to be male than were patients with mental health claims alone; they were less likely to be male than were patients with claims for substance abuse and no mental health services. They were also significantly younger than were patients with substance abuse or mental health utilization only for two of the firms. The average charges for people with dual diagnoses were higher than those for patients with substance abuse or mental health claims only.

Trends in office-based psychiatric practice

OBJECTIVE

The authors examine trends in the composition and duration of visits to psychiatrists in office-based psychiatric practice.

METHOD

An analysis was performed of physician-reported data from the 1985 and 1995 National Ambulatory Medical Care Surveys focusing on visits to physicians specializing in psychiatry. Secular changes in visit characteristics were assessed, and mean visit durations were determined for selected sociodemographic and clinical groups.

RESULTS

In the decade between 1985 and 1995, visits in office-based psychiatry became shorter, less often included psychotherapy, and more often included a medication prescription. The proportion of visits that were 10 minutes or less in length increased. A shortening in visit duration was most evident for younger patients, privately insured patients, and patients who were not prescribed a psychotropic medication. In the 1995 survey, 6.8% of the psychiatric visits included patient contact with another health care professional.

CONCLUSIONS

Changing financial arrangements and new pharmacologic treatments may have contributed to these changes in practice style.

Behavioral health benefits in employer-sponsored health plans, 1997

Data for 1997 show that three-quarters or more of employer-sponsored health plans continue to place greater restrictions on behavioral health coverage than on general medical coverage. The nature of these restrictions varies by plan type. Some improvement in the treatment of mental health/substance abuse (MH/SA) benefits in employer plans may be occurring, however. Comparisons with data from 1996 show that the proportion of plans with benefits for "alternative" types of MH/SA services, such as nonhospital residential care, has increased. Further, the proportion with special limitations on these benefits shows a modest decrease.

Inpatient treatment of comorbid psychiatric and substance abuse disorders: comparison of public sector and privately insured populations

Public health delivery systems are increasingly compared to private systems as policymakers continue to focus on reducing the costs of care. However, there are very few studies comparing trends in utilization and cost between public and private providers. This study examines discharge abstract records for VA patients and insurance claims data for a national sample of privately insured individuals to investigate trends in inpatient utilization and costs for dually diagnosed individuals in these two systems. Although the substantial differences in the populations treated could account for the differences in these measures across systems, this study is useful in illustrating the possibilities and limitations of system comparisons.

Practice patterns of international and U.S. medical graduate psychiatrists

OBJECTIVE

The practice patterns of international medical graduate (IMG) and U.S. medical graduate (USMG) psychiatrists were compared.

METHOD

Using data from the 1996 National Survey of Psychiatric Practice, the authors compared IMGs and USMGs in terms of demographic characteristics, practice settings, patients' clinical characteristics, and sources of reimbursement.

RESULTS

The IMGs surveyed tended to be older than USMGs, included a higher proportion of women, and were more racially heterogeneous. They worked longer hours, worked more frequently in the public sector, and treated a higher proportion of patients with psychotic disorders. The IMGs also received a higher percentage of their income than USMGs from Medicaid and Medicare, whereas the reverse was true of self-payment. Most of these differences remained significant after psychiatrist's age, gender, race, board certification, and work setting were controlled for.

CONCLUSIONS

IMG and USMG psychiatrists have different practice patterns. Policies that substantially decrease the number of IMG psychiatrists may adversely affect the availability of psychiatrists to treat minorities and other underserved populations.

Costs and utilization of substance abuse care in a privately insured population under managed care

OBJECTIVE

Cost and utilization patterns of substance abuse and mental health treatment under private, employer-sponsored, managed behavioral health care plans were examined.

METHODS

Data were from claims made in 1995 in 93 behavioral health care plans covering 617,133 members. Rates of use of mental health and substance abuse care were determined, as were payments by insurers and patients for the two types of care. Means were calculated per plan member and per user of either of these service types.

RESULTS

Approximately .3 percent of plan members used any substance abuse services; 5.2 percent used mental health services. However, among substance abuse patients, average costs were more than twice as high as average costs for mental health patients. For substance abuse treatment, the annual cost per user was $2,188, compared with $979 for users of mental health care. Annual per-member costs were $6.51 for substance abuse treatment and $50.08 for mental health care. Higher costs for substance abuse treatment reflected greater rates of use of both inpatient and intensive outpatient treatment. Overall, substance abuse costs represented 13 percent of insurance payments for behavioral health care and perhaps .4 percent of the cost of health insurance overall.

CONCLUSIONS

Substance abuse coverage accounts for a small fraction of insurance payments for behavioral health coverage and a very small fraction of insurance payments for both physical and behavioral health care.

Mental disorders and access to medical care in the United States

OBJECTIVE

The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults.

METHOD

The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables.

RESULTS

While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care.

CONCLUSIONS

People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.

Physical health, depressive symptoms, and managed care enrollment

OBJECTIVE

This study used a national employee survey to test the hypothesis that symptomatic individuals in general, and individuals with depressive symptoms in particular, are disproportionately enrolled in fee-for-service health care plans as compared to health maintenance organizations (HMOs).

METHOD

The study analyzed data from the 1993 Employee Health Care Value Survey, a questionnaire distributed to employees of three large corporations. The sample comprised 20,283 employees covering six U.S. geographic regions and 46 health plans. The authors used logistic regression to model the association between HMO enrollment and presence of physical and depressive symptoms, measured by subscales derived from the Medical Outcomes Study 36-item Short-Form Health Survey, adjusting for health, demographic, and insurance variables.

RESULTS

In unadjusted models, enrollees in fee-for-service plans had higher rates of both depressive and physical symptoms than HMO enrollees. After adjustment for age alone or for age and other potential confounders, there was no difference in physical symptoms between plan types. However, individuals with high levels of depressive symptoms were 16% less likely to be enrolled in HMOs than in fee-for-service plans after adjustment for age, other demographic variables, physical health status, and insurance characteristics.

CONCLUSIONS

This study provides evidence that symptomatic individuals are more likely to be enrolled in fee-for-service plans than in HMOs. While much of the effect for physical symptoms may be explained by differences in demographic variables, particularly age, the difference in depressive symptoms appears to be independent of those variables.

Do treatment restrictions imposed by utilization management increase the likelihood of readmission for psychiatric patients?

OBJECTIVES

The use of utilization management as a cost-containment strategy has led to debate and controversy within the field of mental health. Little is currently known about how this cost-containment approach affects patient care or quality. The aim of this investigation was to determine whether treatment restrictions imposed on privately insured psychiatric patients by a utilization management program affected the likelihood of readmission.

METHODS

The utilization management program included three review activities: preadmission certification, concurrent review, and case management. During a 5-year period (1989-1993), 3,073 inpatient reviews were performed on 2,443 privately insured psychiatric patients. Using logistic regression, restrictions imposed by utilization management on length-of-stay in relation to 60-day readmission rates were investigated.

RESULTS

The most common diagnoses among the psychiatric patients whose care was reviewed were alcohol dependence (22.9%), recurrent depression (22.5%), and single-event depression (20.8%). On average, 22.4 days of inpatient psychiatric treatment was requested through the review procedures, and 15.5 days of care were approved by the utilization management program. Of the 2,443 patients reviewed, 7.9% had a readmission within 60 days of their initial admission. Patients whose length-of-stay was restricted by utilization management were more likely to be readmitted. For each day that the requested length-of-stay was reduced, the adjusted odds of readmission within 60 days increased by 3.1% (P = 0.004).

CONCLUSIONS

The utilization management program restricted access to inpatient psychiatric care by limiting length of stay. Although this approach may promote cost containment, it also appears to increase the risk of early readmission. Continuing attention should be paid to investigating the effects on quality of utilization management programs aimed at containing mental health costs.

Psychiatric hospitalization characteristics associated with insurance type

This study examines the relationship among types of insurance and characteristics of inpatient psychiatric treatment. Data include 46,998 adult psychiatric or substance abuse cases from all 1991-1992 Washington State discharges from short-stay general hospitals. Large and significant differences among payers exist in treatment characteristics, controlling for diagnosis and patient age. For example, length of stay is longest among commercial and Medicare payers. Emergency admissions are more common among public payers, and elective admissions are more common among private payers, including HMOs. Results and discussed in light of policy and administration issues that will arise as financing for mental health services comes under greater capitation.

Use of health care services by persons with panic symptoms

OBJECTIVE

Patients with panic symptoms are heavy users of the health care system, although many do not seek care specifically for those symptoms. This study documents utilization of various sources of health care of subjects with panic symptoms, including those who met criteria for panic disorder and those with infrequent panic, distinguishing between use specifically for panic symptoms and use for reasons not related to panic.

METHODS

This community-based sample, predominantly Mexican American and female, included 97 subjects with panic symptoms and 97 matched control subjects with no panic symptoms. Data were collected on two-month utilization of various sources of health care both within and outside the mainstream health care system, barriers to access to care, and levels of medical insurance coverage.

RESULTS

Subjects with panic symptoms had higher utilization rates for the services of psychiatrists and psychologists and for ambulance services than control subjects. Subjects who met criteria for panic disorder and who sought care specifically for panic symptoms generally accounted for the differences between the group with panic symptoms and the control group. The two groups differed little in barriers to access, but the control group reported that their medical insurance covered more types of services.

CONCLUSIONS

Compared with control subjects, subjects with panic symptoms reported higher rates of health care utilization despite having less insurance coverage and experiencing similar barriers to access. The higher rate was due to increased utilization of health care by subjects who met criteria for panic disorder and to help seeking specifically for symptoms of panic.

Foster Higgins National Survey: trends in behavioral benefits

Most employer-sponsored health insurance plans provide some coverage for mental health and addiction treatment. However, analysis of over 3,000 employer benefit plans reveals wide variation in the level and scope of behavioral health benefits. Of all commercially insured employees and dependents, 77 percent are currently enrolled in health maintenance organizations (HMOs), preferred provider organizations (PPOs), or point-of-service (POS) managed care plans. This article documents the differences among behavioral health coverage packages in these three different types of managed care organizations (MCOs), and the lower levels of behavioral health coverage compared with coverage for other medical care. The author states that some employers are selecting single-specialty managed behavioral carve-out plans specifically to increase benefit levels and improve quality of care.

Psychiatric findings among child psychiatric inpatients grouped by public and private payment

OBJECTIVE

The study compared school-age psychiatric inpatients whose care was publicly funded with those whose care was privately funded to determine whether the public patients presented with more psychiatric risk factors and more psychiatric problems.

METHODS

Retrospective chart review was used to collect data on the demographic and personal characteristics, behavior in the hospital, and response to milieu treatment of 40 public patients and 40 private patients. Half of each group were admitted during 1985-1986, and half during 1991-1993. Characteristics of the two groups were compared, and trends over time were examined.

RESULTS

The public group presented for hospitalization with significantly more risk factors and psychiatric problems. Public status predicted the use of certain interventions, such as time-outs and physical holding. Public patients responded less positively to the treatment program. They had three times the number of bed-days as the private group during 1991-1993.

CONCLUSIONS

Public patients require more intensive and extensive inpatient treatment and will be more profoundly affected by the restrictions on psychiatric inpatient care in the current climate of fiscal restraint.

Mental health care use, morbidity, and socioeconomic status in the United States and Ontario

This study focuses on mental health problems and compares the association of demographic and socioeconomic factors to the use of mental health specialty care and general medical care in the United States and the Canadian province, Ontario. It also examines how lack of insurance coverage in the United States and perceived need for care affects differences between the two countries. We employ a cross-sectional study design using the 1990 U.S. National Comorbidity Survey and the 1990 Mental Health Supplement to the Ontario Health Survey. Overall, 8.8% of Americans report one or more visits to the health sector for a mental health problem, compared to 6.9% of Canadians in Ontario. Americans with the highest incomes and no mental morbidity are much more likely to receive services than their Canadian counterparts. By contrast, Americans with the lowest incomes and high morbidity are much less likely to receive services for mental health problems than a similar group of Canadians. These results suggest that universal and comprehensive coverage, as exists in Ontario, does not necessarily lead to increased use of services with low value. However, the greater prevalence of perceived need for care among Americans with higher socioeconomic status and low mental morbidity suggests that the United States should be cautious in drawing lessons from other countries.

Children's access to mental health care: does insurance matter?

Using data from a 1992 community survey of children and their parents (or guardians), we found major gaps in mental health insurance coverage. Interestingly, private insurance had no statistically significant effect on use of mental health services. Youth without insurance coverage and those with public insurance had higher rates of serious emotional disorder than did those with private insurance. The analysis is based on the National Institute of Mental Health's Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study, conducted in three mainland U.S. sites and in Puerto Rico.

Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization

BACKGROUND

While previous studies have compared medical utilization between depressed and nondepressed patients, we conducted a study that focused specifically on patients who had a history of high medical expenditures.

METHODS

This study was designed to determine whether a positive screen for depression is predictive of continued high medical expenditures. Medical utilization data were obtained on 50,000 patients enrolled in the DeanCare health maintenance organization for 2 consecutive years. Consistent high utilizers were identified based on the medical utilization costs (paid by the health maintenance organization) for those 2 consecutive years, 1992 and 1993. A depression screen based on the Medical Outcomes Survey was mailed to 786 high utilizers. Their costs were determined for 1994. Regression analyses identified 1994 costs associated with depression, adjusting for age, sex, benefits package, and medical comorbidity.

RESULTS

Depressed high utilizers were more likely than nondepressed high utilizers to have higher medical costs in 1994. Among high utilizers, depressed patients' 1994 costs were significantly higher ($5764 vs $4227; P < .001), although expenditures for depressed and nondepressed high utilizers were similar for the previous 2 years. The total medical cost associated with depression in 1994, adjusted for age, sex, benefits package, and medical comorbidity, was $1498 per patient.

CONCLUSIONS

In the third year (1994), a positive Medical Outcomes Survey screen for depression in high utilizers was associated with $1498 in higher medical costs. The average actual amount spent on depression treatment accounted for only a small portion of total medical costs for depressed high utilizers in the third year.

Who gets hospitalized in a continuum of care?

OBJECTIVE

To compare children and adolescents hospitalized under a continuum of care with those hospitalized under traditional insurance coverage.

METHOD

With comprehensive data, logistic regressions were used to predict hospitalization and to identify its determinants.

RESULTS

As expected, the probability of being hospitalized was much higher under traditional care. In addition, the predictors of hospitalization differed by site. Accuracy of predictions was high.

CONCLUSIONS

Different kinds of children were hospitalized under a continuum of care than under a traditional insurance system. Hospitalizations under both systems were highly predictable.

Mental health and choice between managed care and indemnity health insurance

OBJECTIVE

Populations enrolled in various health insurance plans may differ in their health care needs. Whether mental health affects choice among competing health plans is not clear. This study examined self-selection by participants in a Swiss indemnity insurance plan that was transformed into a managed care organization that controlled access to specialists through gatekeeping and restricted coverage for psychiatric treatments.

METHOD

Information regarding past use of health services and health status was provided by 421 persons who joined the new managed care organization and 222 nonjoiners. The mental health and somatic health characteristics of these two groups were compared.

RESULTS

In the year preceding the creation of the managed care organization, the nonjoiners had made on average 2.3 more visits to psychiatrists than the joiners but 0.0 to 0.6 more visits to other physicians. The nonjoiners were more likely to have used psychoactive medications but not other medications. The rates of treatment for depression were similar in the two groups. The joiners reported significantly lower mental health status, but not somatic health status, than the nonjoiners.

CONCLUSIONS

Both mental health status and past use of mental health services strongly affected choice of health insurance plan. The effects of somatic health and use of somatic health services on selection were consistently weaker. People who join managed care organizations may have substantial uncovered needs for psychiatric care. Minimum mandatory benefits for mental health care may be an effective countermeasure to unequitable self-selection.