Factors associated with admission to public and private hospitals from a psychiatric emergency screening site

OBJECTIVE

The study examined factors associated with admission to public and private hospitals from a mental health care emergency screening system operating under a longstanding mandate to maximize use of private inpatient treatment.

METHODS

For 206 patients evaluated at the mental health emergency screening site over a two-and-a-half-month period, data were collected on demographic and clinical characteristics, admission history, services received during the emergency encounter, system variables such as time the patient spent at the emergency screening site, number of admission sites asked to accept the patient, and all reasons cited by providers for refusing to admit the patient. Logistic regression was used to develop a model of factors most likely and least likely to be associated with private hospitalization.

RESULTS

Overall, 60 percent of the sample was refused admission by one or more providers, and 55 percent, who were not accepted by and private hospital, became public patients. Private hospital admission was associated with patient or family involvement in referral and disposition, private or Medicaid insurance, a presenting problem of depression or suicidality, and longer time spent at the emergency screening site. Public admission was associated with no insurance, a past history of major public hospitalization, current or past history of assaultiveness, a presenting problem of aggression, and lack of any discharge site.

CONCLUSIONS

Private providers are reluctant to admit patients who have characteristics associated with public hospitalization. In the restructuring of health care, a more fully privatized system will likely be called on to absorb such patients. Their care, treatment, and impact on the system should be carefully monitored and evaluated.

Factors associated with inpatient and outpatient treatment for children and adolescents with serious mental illness

OBJECTIVE

This study describes the distribution of children and adolescents in psychiatric inpatient and outpatient facilities and identifies factors associated with the selection of individuals into inpatient versus outpatient care. SAMPLE DATA: The data are from a 1986 nationally representative sample surveyed by the National Institute of Mental Health.

RESULTS

Results indicate that the vast majority of children and adolescents with psychiatric problems receive outpatient treatment rather than inpatient care. Factors that predict psychiatric hospitalization rather than outpatient care are (1) public or private insurance coverage versus no insurance; (2) previous hospitalization; (3) psychiatric diagnosis of affective or psychotic disorders versus conduct disorders, adjustment disorders, drug and alcohol abuse, and other disorders; and (4) age, with adolescents more likely to be hospitalized than children.

CONCLUSIONS

Further research is needed to explore the role of insurance in mental health sorting processes. Moreover, systematic, controlled research is needed to determine how different financing strategies affect mental health outcomes for children and adolescents.

The relationship between insurance coverage and psychiatric disorder in predicting use of mental health services

OBJECTIVE

This study investigated how insurance coverage for mental health services affects outpatient mental health service utilization among those with and among those without a DSM-III psychiatric diagnosis. The authors used a representative community sample to compare the regression effects of insurance coverage on utilization of mental health services among these subjects.

METHOD

Data are from the second wave of the Piedmont, North Carolina, site of the Epidemiologic Catchment Area project. These data contain DSM-III diagnostic measures derived from the National Institute of Mental Health Diagnostic Interview Schedule as well as measures of insurance coverage and utilization. Responses from 2,889 community residents were analyzed using both ordinary least squares and logistic regression.

RESULTS

In both models, insurance coverage was strongly associated with care among those with as well as among those without a psychiatric disorder. The association between coverage and the probability of care was strongest among those with a disorder.

CONCLUSIONS

The findings are not consistent with the claim that failing to provide insurance coverage will reduce discretionary but not necessary mental health care utilization. They provide evidence that failing to provide insurance coverage will reduce utilization as much or more among those with a psychiatric disorder as among those without. This result has important implications for health care reform.

Outpatient psychotherapy in the United States, I: Volume, costs, and user characteristics

OBJECTIVE

This article provides an overview of the volume, composition, and costs of outpatient psychotherapy in the United States.

METHOD

Data were analyzed from the household section of the 1987 National Medical Expenditure Survey. The authors determined the volume and distribution of psychotherapy visits by provider specialty, setting, source of expenditure, and reason for visit. An examination was made of the demographic characteristics, health status, and mental health utilization profile of psychotherapy users.

RESULTS

In 1987, Americans made 79.5 million outpatient psychotherapy visits at a total cost of $4.2 billion. Most of these visits were to mental health specialists (more than 80%) and were reported to be for the treatment of mental health conditions (63.5%). However, psychotherapy was not provided in a substantial proportion of the visits to mental health specialists (21.1%) or the visits to treat mental conditions (29.8%). Separated and divorced persons, females, whites persons aged 35 to 49 years, and those with more than 15 years of education had a greater likelihood of using psychotherapy. Psychotherapy use was also greater among persons in poor general health and those reporting health-related functional impairments. General medical costs of psychotherapy users exceeded those of nonusers.

CONCLUSIONS

Psychotherapy accounts for approximately 8% of outpatient medical care costs. Users of psychotherapy appear to be more distressed than is commonly assumed: they report poorer general health, higher general medical costs, and more functional impairment than nonusers. Although mental health specialists commonly provide psychotherapy to treat mental disorders, all mental health care is not psychotherapy.

Outpatient psychotherapy in the United States, II: Patterns of utilization

OBJECTIVE

The purpose of this article is to characterize the use of psychotherapy based on episode duration.

METHOD

Data were analyzed from the household section of the 1987 National Medical Expenditure Survey. The authors determined the demographic characteristics, provider and reason for visit distribution, mental and physical health status, and expenditures associated with very short-term (one to two sessions), short-term (three to 10 sessions), intermediate-term (11 to 20 sessions), and long-term (> 20 sessions) psychotherapy.

RESULTS

Long-term psychotherapy accounted for 15.7% of psychotherapy users and 62.9% of total psychotherapy expenditures. Age above 65 years, black race, and less than 12 years of education decreased the likelihood of receiving long-term psychotherapy. Whereas long-term psychotherapy episodes tended to be provided by the specialty sector (65.7%) for specific mental conditions (53.8%), very short-term episodes were predominantly provided by the general medical sector (72.2%) for general medical or unspecified conditions (68.3%). Psychotropic medication use and, to less extent, psychiatric hospitalization tended to be more common among longer- as opposed to shorter-term users.

CONCLUSIONS

Long-term and short-term psychotherapy tend to be provided by different health care professionals for the treatment of different types of health conditions. To help ensure the future of third-party payment for long-term psychotherapy, research is needed to better define the conditions under which long-term psychotherapy achieves benefits that equal or surpass those of other medical services or procedures of similar cost.

Who's minding the data: information system requirements for participating in at-risk contracts

Managed behavioral healthcare organizations that receive capitated payments to provide behavioral healthcare services for a defined population need sophisticated management information systems that allow for two-way data exchange with payors. Such systems must be able to generate data on cost per service and utilization of services by beneficiary population, while incorporating a number of subsystem capabilities. In this article the author reviews the requirements for such an information system, the various potential financial loss points that have made such capabilities essential and the specific features that are demanded--as well as offering suggestions on how to select an information system vendor.

Ethnic differences in use of inpatient mental health services by blacks, whites, and Hispanics in a national insured population

OBJECTIVE

We examine whether ethnic differences in use of inpatient mental health services exist when the usually confounding effects of minority status and culture are minimized or controlled.

DATA SOURCES AND STUDY SETTING

Secondary analyses were conducted using a national insurance claims database for 1.2 million federal employees and their dependents insured by the Blue Cross/Blue Shield (BC/BS) Federal Employees Plan (FEP).

STUDY DESIGN

The Andersen-Newman model of health utilization was used to analyze predisposing, enabling, and need variables as predictors of inpatient mental health utilization during 1983. The study design was cross-sectional.

DATA COLLECTION

The study database was made up of BC/BS insurance claims, Office of Personnel Management employee data, and Area Resource File data.

PRINCIPAL FINDINGS

No significant differences were found among blacks, whites, and Hispanics in the probability of a psychiatric hospitalization or in the number of inpatient psychiatric days. Regression analyses revealed younger age and psychiatric treatment of other family members as significant predictors of a hospitalization; region of residence, younger age, hospital bed availability, and high option plan enrollment were significant predictors of the number of treatment days.

CONCLUSIONS

Ethnic differences in use of inpatient mental health services were not significant in this generously insured population. Further research involving primary data collection among large and diverse samples of ethnic individuals is needed to fully examine the effects of cultural and socioeconomic differences on use of mental health services.

Characteristics of psychoanalytic patients under a nationalized health plan: DSM-III-R diagnoses, previous treatment, and childhood trauma

OBJECTIVE

This article reports the results of a survey to collect data on the characteristics of patients in psychoanalysis under a nationalized health insurance scheme.

METHOD

A questionnaire, to be answered anonymously, was sent to all 174 accredited psychoanalysts in Ontario, Canada. Part 1 of the questionnaire consisted of 38 questions on the analyst's pattern of practice. Part 2, also to be filled out by the analyst, consisted of 452 questions on the demographic characteristics, childhood traumas, DSM-III-R diagnoses, and indications for psychoanalysis of each of the analyst's patients.

RESULTS

One hundred seventeen analysts responded--a survey response rate of 67%--with data on 580 patients. Fifty-nine percent (N = 344) of patients were women, and 41% (N = 236) were men. Eighty-two percent had attempted other forms of treatment, including briefer forms of psychotherapy and medication, prior to psychoanalysis. During childhood, 23% had had traumatic separations, 23% had been sexually abused, 22% had been physically abused, and 21% had had a parent or sibling die. The mean number of adult psychiatric disorders at the beginning of analysis was four, and the mode was two.

CONCLUSIONS

In a nationalized health insurance scheme, the psychoanalytic patients were mostly women, they had high rates of trauma and psychopathology, and they had attempted other forms of briefer treatment before resorting to psychoanalysis.

Paying for mental health and substance abuse care

Fifty-four billion dollars was spent on alcohol/drug abuse and mental health treatment in 1990. These expenditures were concentrated in the area of inpatient psychiatric care and on persons with severe mental health and substance abuse problems. The data on expenditure patterns for mental health and substance abuse care suggest that successful health care reform in this area must implement mechanisms for controlling inpatient utilization and managing the care of persons with the most severe disorders.

Dramatic changes in care: the experience of one psychiatric hospital

Recent and dramatic changes in this country's mental healthcare service are widely documented. To assess the extent and timing of those changes at one private psychiatric hospital, the authors examined length of stay, number of admissions, and patient age for general trends between 1980 and 1990 and more closely examined trends between July 1990 and December 1991. We related our findings to data for other private psychiatric hospitals and compared them with data from psychiatric units in general hospitals. The results are discussed in terms of changes in insurance coverage, changing utilization by different age groups, and a national shift from inpatient to outpatient care.

For mental health cost problems, see a specialist

Separating mental health care from other benefits helps keep costs down while improving treatment, experts say.

The effect of insurance benefit changes on use of child and adolescent outpatient mental health services

Use of outpatient mental health services by dependent children younger than 18 years of age enrolled in the Blue Cross and Blue Shield Federal Employees Plan (FEP) is examined in 1978 and 1983 focusing on a cut in benefits and a shift from high- to low-option plan enrollment between those years. While use rates increased from 2.13% to 2.76% by 1983, the average number of visits decreased from 18.9 to 12.8. High-option plan use exceeded low-option plan use in both years--2.26% versus 0.81% in 1978 and 3.58% versus 1.93% in 1983. In addition to benefit plan, ethnicity, parent's education, type of provider, and type of treatment setting also significantly predicted amount of use. Despite the strong evidence of the effects of benefit coverage, it is likely that need exceeded use even in this insured population of children and adolescents. Implications of the findings are discussed in the context of recent dramatic changes in mental service delivery including privatization, managed care initiatives to cut costs, and growing pressures for national health insurance.

Use of inpatient services by a national population: do benefits make a difference?

This study describes changes in the use of inpatient mental health services by children and adolescents under age 18. The data were insurance claims from the Blue Cross and Blue Shield Federal Employees Program. The study focused on a cut in inpatient benefits that occurred between 1978 and 1983. The rate of inpatient hospitalization dropped significantly, and the average number of days also decreased significantly from 45.8 to 27.0 days. This study is among the first to demonstrate that the rate and amount of inpatient care provided for children and adolescents is responsive to variations in benefit coverage.

Characteristics of youths identified from a psychiatric case register as first-time users of services

OBJECTIVE

The study examined associations between sociodemographic factors and first-time use of mental health services by children and adolescents, including whether the patterns differ by age at first treatment contact.

METHODS

The authors examined sociodemographic characteristics of 4,949 youths listed on a psychiatric case register in Monroe County, New York, who were under age 19 when first seen for public mental health treatment between 1987 and 1989. Data on race and type of insurance for patients in the county's four catchment areas were compared with 1980 census data. Insurance was categorized as public (such as Medicaid) or private and was used as a proxy for socioeconomic status.

RESULTS

Both minority and publicly insured youths of low socio-economic status were overrepresented in the treatment population in relation to their numbers in the county, although publicly insured youths from the poorest catchment area were underrepresented in the treatment population. Among children (ages five to 12) in the treatment population, males outnumbered females by 2 to 1, but among adolescents (ages 13 to 18), the numbers were similar. Among minority groups, children receiving first-time mental health services were more likely to have public insurance. Minority adolescents were somewhat more likely to be privately than publicly insured.

The discriminating characteristics of for-profit versus not-for-profit freestanding psychiatric inpatient facilities

This study examines the characteristics that discriminate between ownership types among private, freestanding psychiatric inpatient facilities in the United States. Use of data from the Inventory of Mental Health Organizations (National Institute of Mental Health 1983, 1986), revealed that not-for-profits provide more services and serve more of the underinsured, while for-profits serve the better insured, concentrate primarily on inpatient services, and serve more children, adolescents, and substance abusers. A surplus bed capacity among for-profit psychiatric hospitals is presumed to contribute to lower occupancy rates and less turnover in the for-profit sector. Not-for-profit psychiatric facilities are also found to be more involved in professional training and to be more accessible through emergency services. However, the misclassification test in the discriminant procedure reveals that a significant group of not-for-profit facilities looks more like its for-profit counterpart group than like other not-for-profits. Study findings are interpreted both in terms of debates over the tax-exempt status of not-for-profit hospitals and the potential negative service effects of proprietization.

Green Spring criteria for medical necessity of outpatient treatment and its use in a mental health utilization review program

The authors have developed a two-tiered method for utilization review of outpatient mental health services. The methodology looks at initial and continued treatment evaluation and uses diagnosis, symptoms, plan of treatment, and the Global Assessment Scale (GAS) among other indicators to determine appropriateness of treatment. Preliminary program experience has been positive and is included.

The effects of preferred provider options in fee-for-service plans on use of outpatient mental health services by three employee groups

Descriptions of how preferred provider organizations (PPOs), offered as options to employees enrolled in fee-for-service plans, affected use of outpatient mental health services are provided. Data are from the RAND Preferred Provider Organization Study, which has a sample of employees who enrolled in fee-for-service plans 1 year before and 2 years after a PPO option was offered by three employers in two U.S. sites. To study effects of the optional PPOs on access to mental health care, usage patterns among those who initially stated that they did or did not intend to use PPO providers were examined. By the end of the second post-PPO year, employees had a similar annual probability of having an outpatient mental health visit whether or not they initially intended to use PPO providers. However, during the first post-PPO year, there was a decrease in the probability of use for those initially intending to use PPO providers, relative to those who did not intend to do so, among employees who had no regular medical provider. To study effects of the PPO option on usage levels of mental health care services, users of mental health services who primarily visited PPO were compared with those who primarily visited non-PPO providers. Users who visited PPO providers had significantly lower levels of use, controlling for other factors, than those who primarily visited non-PPO providers. Therefore, despite lower cost sharing for services received from PPO providers, the PPO option appeared to lower outpatient mental health care costs while having no more than a transient effect on access. This study did not evaluate mental health outcomes.

Understanding the forces that drive mental health and chemical dependency utilization

Economic and social forces combined with imprecise treatment standards are creating a virtual explosion in employer costs attributable to mental and chemical dependency disorders. To develop appropriate programs for managing these costs, the forces that drive utilization must be understood.