Implementing publicly funded risk contracts with community mental health organizations

The study analyzed the experience of the Los Angeles County Department of Mental Health with implementation of new contractual arrangements for services for patients with severe mental illness. The arrangements shifted the financial risk for treatment to community organizations and paid a fixed annual rate per enrolled patient without further adjustment for severity of illness. Patients were assigned to the program based on high prior treatment costs. The new contractual approach enhanced programs' flexibility and accountability and increased their emphasis on principles of psychosocial rehabilitation. Challenges in implementation included disenrollment of the majority of assigned patients by the community organizations at risk for high treatment costs. Prior treatment costs for continuing cases, while high, were lower than those for disenrolled cases. Existing information systems provided limited clinical and cost data, making it difficult to monitor providers' performance. Risk contracting required substantial clinical, fiscal, and management changes at community organizations and the mental health authority. The analysis suggests that mental health authorities that are planning to institute risk contracts need to balance fiscal incentives with performance guarantees and to pay particular attention to information systems requirements and to the severity of patients' illness. Although risk contracts present challenges, they can lead to improvements in service delivery that persist beyond the implementation phase.

Empirically defined health states for depression from the SF-12

OBJECTIVE

To define objectively and describe a set of clinically relevant health states that encompass the typical effects of depression on quality of life in an actual patient population. Our model was designed to facilitate the elicitation of patients' and the public's values (utilities) for outcomes of depression.

DATA SOURCES

From the depression panel of the Medical Outcomes Study. Data include scores on the 12-Item Short Form Health Survey (SF-12) as well as independently obtained diagnoses of depression for 716 patients. Follow-up information, one year after baseline, was available for 166 of these patients.

METHODOLOGY

We use k-means cluster analysis to group the patients according to appropriate dimensions of health derived from the SF-12 scores. Chi-squared and exact permutation tests are used to validate the health states thus obtained, by checking for baseline and longitudinal correlation of cluster membership and clinical diagnosis.

PRINCIPAL FINDINGS

We find, on the basis of a combination of statistical and clinical criteria, that six states are optimal for summarizing the range of health experienced by depressed patients. Each state is described in terms of a subject who is typical in a sense that is articulated with our cluster-analytic approach. In all of our models, the relationship between health state membership and clinical diagnosis is highly statistically significant. The models are also sensitive to changes in patients' clinical status over time.

CONCLUSIONS

Cluster analysis is demonstrably a powerful methodology for forming clinically valid health states from health status data. The states produced are suitable for the experimental elicitation of preference and analyses of costs and utilities.

Managed behavioral health services for children under carve-out contracts

OBJECTIVE

Service costs and utilization patterns of children in carved-out behavioral health care plans were examined and compared with those of adults.

METHODS

Twelve-month data on utilization and costs of behavioral health care from one managed behavioral health care carve-out organization, United Behavioral Health, were examined for three age groups of children--birth to five years, six to 12 years, and 13 to 17 years-and for adults. More than 600,000 enrollees in 108 different plans were included in the data. Rates of use and intensity of use were examined separately by type of service-inpatient, outpatient, and partial hospitalization.

RESULTS

Only a small number of all enrollees used any behavioral health care services--4.2 percent used outpatient services, .3 percent used inpatient services, and .2 percent used partial hospitalization services. Adolescents were more than twice as likely as adults and about seven times as likely as children aged 6 to 12 to use inpatient services. Adolescents also had a slightly higher probability of using outpatient care than adults, while younger children had lower rates of outpatient use than adolescents or adults. Adolescents were also more likely than adults and other children to have very high costs of inpatient care (mean costs=$8,975 for adolescents and $4,750 for adults). Adults were more likely than other groups to have higher outpatient costs ($640 for adults and $513 for all children).

CONCLUSIONS

The finding that children, and adolescents in particular, are more likely to have very high inpatient costs compared with adults implies that they may benefit most from the elimination of caps on mental health care costs covered by insurance. This profile of children's behavioral health care utilization patterns can be useful to policy makers in considering expansions in children's health insurance coverage.

Mental health and substance abuse benefits in carve-out plans and the Mental Health Parity Act of 1996

Legislation passed in the fall of 1996 required employers and insurers offering mental health benefits to raise dollar coverage limits on mental health services to the level of medical services. We analyze the benefit designs of 4,000 current behavioral health carve-out plans and contrast them to medical benefits. We find that almost 90 percent of all plans are inconsistent with the current legislation and need to be rewritten in the coming year. The restructuring of designs required by the Parity Act provides a unique opportunity because plans often are inconsistent and unnecessarily complex, a legacy of past attempts by employers to contain costs and control adverse selection and moral hazard in an unmanaged fee-for-service environment. Under managed care, the need for deductibles, limits, or other demand-side cost-sharing mechanisms may have diminished and restructuring outdated designs could benefit both enrollees and employers.

Costs and use of mental health services before and after managed care

This paper tracks access, utilization, and costs of mental health care for a private employer over nine years during which mental health benefits were carved out of the medical plan and managed care was introduced. Prior to the carve-out, mental health costs increased by around 30 percent annually; in the first year after the change, costs dropped by more than 40 percent; in the six follow-up years, costs continued to decline slowly. This cost reduction was not attributable to decreased initial access, as the number of persons using any mental health care increased following the change. Instead, the cost reduction was the result of (1) fewer outpatient sessions per user, (2) reduced probability of an inpatient admission, (3) reduced length-of-stay for an inpatient episode, and (4) substantially lower costs per unit of service.

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

OBJECTIVES

To study costs, access, and intensity of mental health care under managed care carve-out plans with generous coverage; compare with assumptions used in policy debates; and simulate the consequences of removing coverage limits for mental health care as required by the Mental Health Parity Act.

DESIGN

Claims data from 1995 and 1996 for 24 managed care carve-out plans; all plans offered unlimited mental health coverage with minimal co-payments.

OUTCOME MEASURES

Probability of care, intensity of care, and total costs broken down by service type and type of enrollee.

RESULTS

Assumptions used in last year's policy debate overstate actual managed care costs by a factor of 4 to 8. In the plans studied, costs are lower owing to reduced hospitalization rates, a relative shift to outpatient care, and reduced payments per service. However, access to mental health specialty care increased (7.0% of enrollees) compared with the preceding fee-for-service plans (6.5%) or free care in the RAND Health Insurance Experiment (5.0%). Removing an annual limit of $25000 for mental health care, which is the average among plans currently imposing limits, will increase insurance payments only by about $1 per enrollee per year. Children are the main beneficiaries of expanded benefits.

CONCLUSIONS

Concerns about costs have stifled many health system reform proposals. However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates. For mental health care, the cost consequences of improved coverage under managed care, which by now accounts for most private insurance, are relatively minor.

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.

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

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

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

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

Provider choice and continuity for the treatment of depression

The role of specialist versus generalist providers regularly surfaces in health-care reform debates about costs and quality of care. By changing incentives to seek and deliver care, different payments systems can affect both the probability of initial specialty care and the duration of this patient-provider relationship. The authors compare provider selection (psychiatrist, nonphysician mental-health specialist, general medical provider) and duration of this relationship among depressed patients in prepaid and fee-for-service plans. Regarding initial care, depressed patients in prepaid plans are significantly less likely to see a psychiatrist and more likely to see a nonphysician mental-health specialist than patients in fee-for-service plans. Although the mix of providers differs, patient demographic and clinical characteristics have similar effects on specialty in both payment systems, ie, there are no differences in who gets specialty care by type of payment, but in how many get specialty care. The average duration of a patient-provider relationship is significantly shorter in prepaid plans. Durations are significantly shorter for patients of both psychiatrists and general medical providers in prepaid plans, but do not differ by payments type for nonphysician therapists. In both payments systems, patients of nonphysician providers end the relationship sooner than patients of psychiatrists or general medical providers. Although the authors find provider switching to be associated significantly with discontinuing antidepressant medication, there is no significant direct effect on patient health outcomes.

Comparison of cryopreservation of supernumerary pronuclear human oocytes obtained after intracytoplasmic sperm injection (ICSI) and after conventional in-vitro fertilization

A comparison was made of pronuclear stage human oocytes obtained either after classical in-vitro fertilization (IVF) or after intracytoplasmic sperm injection (ICSI). After ICSI or IVF, three fertilized oocytes from each patient were kept in culture for a further 24 h before embryo transfer. The surplus oocytes were cryopreserved using the 'open freezing system' and 1,2-propanediol and sucrose as cryoprotectants. A cohort of 817 and 1626 oocytes in pronuclear stage were frozen after IVF and ICSI respectively. Of these, 333 and 744 zygotes have been thawed, of which 78 and 76.5% were morphologically intact zygotes after IVF and ICSI respectively. From the 204 (ICSI) and 89 (IVF) zygote transfers performed, 34 (17%) and 18 (20%) pregnancies were established. Both groups showed a similar abortion rate of approximately 20%. It is concluded that pronuclear stage oocytes resulting from ICSI can be successfully frozen/thawed and the survival and pregnancy rates achieved are comparable to those for zygotes obtained after IVF.

Mini-swim-up: a new technique of sperm preparation for intracytoplasmic sperm injection

PURPOSE

The male factor is nowadays one of the major problems in the treatment of infertility. New methods of assisted fertilization such as the intracytoplasmic sperm injection (ICSI) show better fertilization and pregnancy rates than classical IVF.

METHOD

In this study, we present a new technique of sperm preparation: the "mini-swim-up."

CONCLUSION

This technique, used in conjunction with the ICSI procedure, improves pregnancy and fertility rates in cases of severe oligoasthenoteratozoospermia.

Mental health care utilization in prepaid and fee-for-service plans among depressed patients in the Medical Outcomes Study

OBJECTIVE

We compare mental health utilization in prepaid and fee-for-service plans and analyze selection biases.

DATA SOURCE

Primary data were collected every six months over a two-year interval for a panel of depressed patients participating in the Medical Outcomes Study, an observational study of adults in competing systems of care in three urban areas (Boston, Chicago, and Los Angeles).

STUDY DESIGN

Patients visiting a participating clinician at baseline were screened for depression, followed by a telephone interview, which included the depression section of the NIMH Diagnostic Interview Schedule. Patients with current or past lifetime depressive disorder and those with depressed mood and three other lifetime symptoms were eligible for this analysis. We analyze mental health utilization based on periodic patient self-report. ANALYTIC METHODS: We use two-part models because of the presence of both nonuse and skewness of use. Standard errors are corrected nonparametrically for correlations across observations due to clustered sampling within participating physicians and repeated observations on the same individual.

PRINCIPAL FINDINGS

The average number of mental health visits was 35-40 percent lower in the prepaid system, adjusted and unadjusted for observed differences in patient characteristics, including health status. Utilization differences were concentrated among patients of psychiatrists, with only minor differences among patients of general medical providers. Analyzing the effect of switches that patients make between payment systems over time, we found some evidence of adverse selection into fee-for-service plans based on baseline utilization, but not based on utilization at the end of the study. In particular, after adjusting for observed patient characteristics and health status, patients switching out of prepaid plans had higher baseline use than predicted, whereas patients switching out of fee-for-service had lower use than predicted. Switching itself appears to be related to an immediate decline in utilization and was not followed by an increase or "catch-up" effect.

CONCLUSIONS

The absence of the commonly found "catch-up" effect following switching and the significant decrease in utilization during the switching period suggests an interruption in care that does not occur for patients staying within a payment system. This finding emphasizes the need for integrating new patients quickly into a system, an issue that should not be neglected in the current policy discussion.

How can care for depression become more cost-effective?

OBJECTIVE

To determine the cost and health effects of changes in the content and quality of care for depressed patients treated in prepaid general medical practices (internal and family medicine) and mental health specialty practices and shifts in the proportion of patients treated in general medicine.

METHODS

Cost-effectiveness analysis and simulations, which are empirically based on data from the Medical Outcomes Study.

OUTCOME MEASURES

Change in serious functional limitations, annual treatment costs per patient, and costs per reduction in one functional limitation.

RESULTS

More appropriate care for depression (increased counseling, use of appropriate antidepressant medications, or avoidance of regular minor tranquilizer use) improves functioning outcomes. Although this approach increases total costs of care, it also improves the value of care because each dollar spent on care now provides more benefits in terms of health improvements. In contrast with the effects of more appropriate care for depression, the trend away from mental health specialty care and toward general medical provider care under current treatment patterns reduces costs, worsens outcomes, and does not increase the value of health care spending in terms of health improvement per dollar.

CONCLUSION

Quality improvement measures that roughly follow practice guidelines for depression can improve outcomes and the value or cost-effectiveness of care, but at increased treatment costs; shifting patients away from mental health specialists decreases costs but worsens functioning outcomes. The best strategy for making care for depression more cost-effective is through quality improvement, not through changing specialty mix. Yet combining these strategies may achieve better outcomes, lower treatment costs, and better value of care compared with current practice patterns. To realize this potential, however, substantial quality improvement of care for depression is necessary in general medical practice.

Care for depression in a changing environment

The U.S. health care system is quickly changing, but is it moving in the right direction? Focusing on care for clinical depression as a test case, this paper summarizes our previously published findings on the effects of various payment strategies, managed care, and primary care gatekeepers on the outcomes and costs for the treatment of mental health conditions. We then synthesize the policy implications of these findings for achieving value of care, lower costs, and good health outcomes.

Switches between prepaid and fee-for-service health systems among depressed outpatients: results from the Medical Outcomes Study

We analyzed switches between prepaid and fee-for-service health care plans among depressed outpatients in the longitudinal part of the Medical Outcomes Study. Patients of mental health specialists in fee-for-service plans had the lowest adjusted rate of plan switching (8.1%), compared to fee-for-service general medical patients (13.5%) and prepaid patients of both types of providers (10.1% to 11.7%). Although there were no substantial differences in initial sickness by payment system among enrolled patients, differing switching rates by provider specialty and payment system indicated biased selection over time. In addition, we found that married, nonwhite, and wealthier individuals were significantly more likely to leave fee-for-service than prepaid care plans. We analyzed whether system switching had an effect on patient satisfaction and outcomes. None of the results were highly significant, but the power of the data to analyze this issue was limited. Nevertheless, it appears that patients switching from prepaid to fee-for-service may be at risk for poorer functioning outcomes, although there was no similar effect on mental health status.

Outcomes for adult outpatients with depression under prepaid or fee-for-service financing

OBJECTIVE

To compare change over time in symptoms of depression and limitations in role and physical functioning of patients receiving prepaid or fee-for-service care within and across clinician specialties.

METHOD

Observational study of change in outcomes over 2 years for 617 depressed patients of psychiatrists, psychologists, other therapists, and general medical clinicians in three urban sites in the United States.

RESULTS

Psychiatrists treated psychologically sicker patients than other clinicians in all payment types. Among psychiatrists' patients, those initially receiving prepaid care acquired new limitations in role/physical functioning over time, while those receiving fee-for-service care did not. This finding was most striking in independent practice associations but varied by site and organization. Patients of psychiatrists were more likely to use antidepressant medication than were patients of other clinicians, but among psychiatrists' patients, there was a sharp decline over time in the use of such medication in prepaid compared with fee-for-service care. Outcomes did not differ by payment type for depressed patients of other specialty groups, or overall.

CONCLUSION

Depressed patients of psychiatrists merit policy interest owing to their high levels of psychological sickness. For these patients, functioning outcomes were poorer in some prepaid organizations. The nonexperimental evidence favors (but cannot prove) an explanation based on care received, such as a reduction in medications, rather than on preexisting sickness differences.

Structure-activity relationships leading to WAY-121,520, a tris aryl-type, indomethacin-based, phospholipase A2 (PLA2)/leukotriene biosynthesis inhibitor

We were intrigued by reports of the inhibition of phospholipase A2 (PLA2) by indomethacin. In order to increase the potency of the indomethacin system as an inhibitor of PLA2, it was decided to make more lipophilic analogs. Indeed, covalent attachment of a quinoline ring to the methoxy substituent of indomethacin affords WAY-122,220 which is almost an order of magnitude more potent than indomethacin in inhibiting human synovial fluid PLA2 (IC50 = 15 and 145 microM, respectively). The N-p-chloro-benzyl analog of this compound, WAY-121,520, was an even more potent inhibitor of PLA2 (IC50 = 4 microM). Structural analyses and molecular modeling suggest that these compounds may inhibit PLA2 by mimicking arachidonic acid. WAY-121,520 is also a potent leukotriene biosynthesis inhibitor both in the rat PMN and mouse macrophage assays (IC50 = 10 and 4 nM, respectively), possibly acting via a 5-LO (5-lipoxygenase) translocation inhibition mechanism. The multiple actions of WAY-121,520 may contribute to its favorable anti-inflammatory profile.

Pharmacological characterization of WAY-121,520: a potent anti-inflammatory indomethacin-based inhibitor of 5-lipoxygenase (5-LO)/phospholipase A2 (PLA2)

WAY-121,520 inhibited human synovial fluid PLA2 (HSF-PLA2) (IC50 = 4 microM) using arachidonic acid-labeled E. coli as substrate. Further biochemical characterization of WAY-121,520 demonstrated potent inhibition of 5-lipoxygenase (5-LO) activity in the murine macrophage (LTC4, IC50 = 4 nM) and rat PMN (LTB4, IC50 = 10 nM) and an ability to antagonize LTD4 binding to isolated guinea-pig trachea (pKB = 6.0). In vivo anti-inflammatory activity was noted in murine TPA-induced (ED50 = 91 micrograms/ear) and arachidonic acid-induced (66% inhibition at 400 micrograms/ear) ear edema and in leukotriene-dependent antigen-induced bronchoconstriction in the guinea pig (73% inhibition at 50 mg/kg, p.o.). WAY-121,520 represents a novel series of indomethacin-based inhibitors of PLA2 with anti-inflammatory activity resulting from a combination of biochemical activities (inhibition of 5-LO and PLA2 and LTD4 antagonism). This agent may provide added therapeutic efficacy over more selective inhibitors.

Effects of progesterone on gonadotropin-releasing hormone receptor concentration in cultured estrogen-primed female rat pituitary cells

Acute (0.5-4 h) treatment of estradiol (E)-primed female rat pituitary cells with progesterone (P) augments gonadotropin-releasing hormone (GnRH)-induced LH release, whereas chronic (48 h) P-treatment reduces pituitary responsiveness to the hypothalamic decapeptide. Dispersed E-primed (48 h, 1 nM) rat pituitary cells were cultured for 4 or 48 h in the presence of 100 nM P to assess the effects of the progestagen on GnRH receptors and on gonadotrope responsiveness to the decapeptide. P-treatment (4 h) significantly augmented GnRH-receptor concentrations (4.44 +/- 0.6 fmol/10(6) cells) as compared to cells treated only with E (2.6 +/- 0.5 fmol/10(6) cells). Parallel significant changes in GnRH-induced LH secretion were observed. The acute increase in GnRH-receptor number was nearly maximal (180% of receptor number in cells treated with E alone) within 30 min of P addition. Chronic P-treatment (48 h) significantly reduced pituitary responsiveness to GnRH as compared to E-treatment. The GnRH-receptor concentrations (3.9 +/- 0.6 fmol/10(6) cells), however, remained elevated above those in E-primed cells. GnRH-receptor affinity was not influenced by any of the different treatments. These results indicate that the acute facilitatory P-effect on GnRH-induced LH release is at least chronologically closely related to an increase in GnRH-receptor concentration. The chronic negative P-effect on pituitary responsiveness to GnRH, however, shows no relation to changes in available GnRH receptors.