Identifying catastrophic psychiatric cases. Targeting managed-care strategies

Identifying clinical appropriateness in the catastrophic psychiatric case

Catastrophic psychiatric illness has been commonly identified by demographic factors such as cost (greater than $10,000) and length of treatment (greater than 30 days). In order to determine which cases could have been better managed in order to prevent the high cost and long length of treatment, clinical identifiers were formulated by the authors. The authors examined reviews of cases identified by third-party payors and reviewed by psychiatrist reviewers. They found that the majority of the catastrophic cases were not truly clinically catastrophic but were catastrophic in terms of resource utilization. This was due to patient non-compliance, poor treatment management and poor benefit management. The authors conclude that catastrophic costs and extended treatment could be prevented, in some cases, through the use of better practice patterns and case management.

The impact of private utilization management on psychiatric care: a review of the literature

Psychiatric care in the United States is increasingly practiced subject to some form of utilization management (UM) by third parties. This paper reviews recent studies of UM in the privately insured mental health sector, and finds some limited evidence that UM reduces utilization and costs to the payer. Less is known about UM's effect on mental health outcomes, or its financial impacts on patients, providers, and society. Implications concerning the regulation of UM are discussed, and suggestions are made for future research on the impact of UM.

A thirty-year retrospective study of hospitalization among severely mentally ill patients

This study examines the effects of deinstitutionalization policies on psychiatric hospitalization rates over a thirty-year period. It is based on a retrospective study of successive hospitalizations in severely disabled patients. The data indicate that in any five-year period these patients still spend over 20% of their time in hospital. For patients who have stayed for a total of more than one year every five years in hospital, the average length of stay has been decreasing far less rapidly in the last fifteen years than it had previously. Patients who were first admitted after 1971 spent proportionally as much time in hospital as those whose first stay was earlier. These results show that the groups primarily affected by deinstitutionalization are those who were first hospitalized prior to the 1970s and those who are the heaviest hospital users. However, the data from the patients admitted since the seventies seem to reveal that the process of change may have reached its limits.

Developments in alcoholism treatment

Alcohol treatment systems expanded and diversified considerably over the past decade. This reflects adaptation to a variety of forces, including developments in national health care financing and policy, changes in other health care systems with which alcohol treatment had strong ties, the more diffuse effects of social movements and a "drying trend" in American public opinion, as well as agitation by advocacy and provider groups within the alcohol field. Drawing on national monitoring data, this chapter reviews developments at the levels of financing policy, organizations, client populations, and treatment modalities, documenting expansion in private sector alcohol treatment units, a growing emphasis on providing outpatient treatment, a merger between services for alcohol and drugs at the organizational and conceptual levels, increases in service delivery to coerced populations, as well as demographic change in alcohol treatment caseloads during the 1980s.

High-risk clients and mental health care management

A framework characterizing high-risk psychiatric patients by their probability of hospitalization and lengthy stay is introduced. Risk curves are then developed for each patient showing the potential impact of mental health case management on patient risk. Preliminary empirical analysis reveals that although most patients benefit from the case management intervention, some 30% of the client population may face an increase in risk of hospitalization and lengthy stay.