Specialty health care, treatment patterns, and quality: the impact of a mental health carve-out on care for depression

Classification of anxiety and depressive disorders: problems and solutions

The American Psychiatric Association and the World Health Organization have begun to revise their classifications of mental disorders. Four issues related to these revisions are discussed in this study: the structure of the classifications, the relationship between categories and dimensions, the sensitivity of categorical thresholds to definitions, and maximizing the utility and validity of the diagnostic process. There is now sufficient evidence to consider replacing the present groupings of disorders with an empirically based structure that reflects the actual similarities among disorders. For example, perhaps the present depression and anxiety disorders would be best grouped as internalizing disorders. Most mental disorders exist on a severity dimension. The reliability and validity of the classification might be improved if we accepted the dimensional nature of disorders while retaining the use of categorical diagnoses to enhance clinical utility. Definitions of the thresholds that define categories are very susceptible to detail. In International Classification of Diseases-11(ICD-11) and Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), disorders about which there is agreement should be identically defined, and disorders in which there is disagreement should be defined differently, so that research can identify which definition is more valid. The present diagnostic criteria are too complex to have acceptable clinical utility. We propose a reduced criterion set that can be remembered by clinicians and an enhanced criterion set for use with decision support tools.

Association between pre-hospital vitamin D status and hospital-acquired new-onset delirium

The goal of the present study was to determine whether pre-hospital 25-hydroxyvitamin D (25(OH)D) levels are associated with the risk of hospital-acquired new-onset delirium (HANOD). We performed a retrospective cohort study of 4508 adult inpatients at two teaching hospitals in Boston from 1993 to 2006. All patients had 25(OH)D levels measured before hospital admission. The main outcome measure was HANOD, defined as the onset of delirium during an acute care hospitalisation. Patients with a history of delirium or dementia, or those with a diagnosis of delirium or dementia upon acute care hospitalisation were excluded from the analysis. To test the association of pre-hospital 25(OH)D levels with HANOD, we constructed a multivariable logistic regression model to adjust for clinically relevant covariates. Among our patient cohort, the mean 25(OH)D level was 22 (sd 13) ng/ml and approximately 4% of patients met the criteria for HANOD. Following adjustment for age, sex, race (non-white v. white), patient type (medical v. surgical) and Deyo-Charlson Index, patients with 25(OH)D levels < 10, 10-19·9 and 20-29·9 ng/ml had higher odds of HANOD than patients with 25(OH)D levels ≥ 30 ng/ml: OR 2·15 (95% CI 1·32, 3·50), OR 1·54 (95% CI 0·98, 2·43) and OR 1·23 (95% CI, 0·76, 1·99), respectively. These data support the rationale for randomised, controlled trials to test the role of vitamin D supplementation in the prevention of HANOD.

A comparison of acute psychiatric care under Medicaid carve-outs, HMOs, and fee-for-service

This study compares the use of acute psychiatric hospitalization; selected outcomes, including rehospitalization; as well as costs associated with the health maintenance organization (HMO), carve-out, and fee-for-service models as implemented in the Massachusetts Medicaid program between FY1994 and FY2000. This is a longitudinal analysis that primarily uses unduplicated individual data from the Massachusetts Case Mix database. Analyses focus on 56,518 individuals who were psychiatrically hospitalized on acute units within 57 hospitals. They employ Cox regression to compare rehospitalization among the three programs. The hypotheses were strongly supported: HMOs have the most substantial impacts in minimizing service provision, with the carve-out program having an impact intermediate between the HMO and fee-for-service programs. Lower utilization rates were associated with lower overall rates of hospitalization, shorter lengths of stay, fewer repeated stays, and less geographic access and greater displacement of psychiatric patients to medical units. The final model of rehospitalization has an overall predictive accuracy of 59.6%.

The history of managed care and the role of the child and adolescent psychiatrist

The child and adolescent psychiatrist cannot practice in today's world without interacting with the world of insurance and managed care. This article reviews the history of the development of the managed care industry. It also examines the variety of roles clinicians play, whether as members of physician networks, as a peer or utilization reviewers, or as medical directors. The skills required of the physician employee and the contractual and ethical concerns are discussed.

Mental health and substance abuse insurance parity for federal employees: how did health plans respond?

A fundamental concern with competitive health insurance markets is that they will not supply efficient levels of coverage for treatment of costly, chronic, and predictable illnesses, such as mental illness. Since the inception of employer-based health insurance, coverage for mental health services has been offered on a more limited basis than coverage for general medical services. While mental health advocates view insurance limits as evidence of discrimination, adverse selection and moral hazard can also explain these differences in coverage. The intent of parity regulation is to equalize private insurance coverage for mental and physical illness (an equity concern) and to eliminate wasteful forms of competition due to adverse selection (an efficiency concern). In 2001, a presidential directive requiring comprehensive parity was implemented in the Federal Employees Health Benefits (FEHB) Program. In this study, we examine how health plans responded to the parity directive. Results show that in comparison with a set of unaffected health plans, federal employee plans were significantly more likely to augment managed care through contracts with managed behavioral health "carve-out" firms after parity. This finding helps to explain the absence of an effect of the FEHB Program directive on total spending, and is relevant to the policy debate in Congress over federal parity.

Changing mental health gatekeeping: effects on performance indicators

This study evaluated how a change in gatekeeping model at a health maintenance organization affected performance indicators for specialty outpatient mental health care. Gatekeeping in one division changed from in-person evaluations to a call center with routine authorization for the first eight visits. Using 1996-1999 claims data (including 2 years pre- and 2 years postintervention), the study compared performance indicator results in the affected division and another where the model did not change. Subjects included 122,751 continuously enrolled persons. Dependent variables were mental health emergency room use, treatment initiation, treatment engagement, and family treatment for child patients. After controlling for secular trends at the other division and enrollee characteristics, the division that changed gatekeeping experienced no significant impact on most indicators and an increase in family treatment for children. The move to call-center gatekeeping did not appear to have a negative impact on treatment process as reflected in these indicators.

Managed Behavioral Health Care Carve-Outs: Past Performance and Future Prospects

As the managed behavioral health care market has matured, behavioral health carve-outs have solved many problems facing the delivery of behavioral health services; at the same time, they have exacerbated existing difficulties or created new problems. Carve-outs developed to address rising inpatient behavioral health costs and limited insurance coverage. They are based on the economic principles of economies of specialization, economies of scale, price negotiation, and selection. Literature shows that carve-outs have been successful in lowering costs and maintaining or improving access, but results on their impact on quality of care are mixed. In recent years, carve-outs have evolved to take on new roles within the health system, such as coordinating mental and physical health, addressing fragmented public financing systems, and using market power to implement quality improvement. Although not perfect, carve-outs have been instrumental in addressing long-standing challenges in utilization, access, and cost of behavioral health care.

Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.

An episode-based framework for analyzing health care expenditures: an application of reward renewal models

OBJECTIVE

To illustrate an episode-based framework for analyzing health care expenditures based on reward renewal models, a stochastic process used in engineering for describing processes that cycle on and off with "rewards" (or costs) occurring at the end of each cycle.

DATA SOURCES/STUDY SETTING

Data used in the illustration were collected as part of an evaluation of a national initiative to improve mental health services for children and youth. Participants were enrolled in a longitudinal study at a demonstration site and in a comparison community between 1997 and 1999. The illustration involves analyses of mental health expenditures at the two sites and of the dynamics of service use behind those expenditures.

DATA COLLECTION/EXTRACTION METHODS

Services data were derived from management information systems as well as patient records at inpatient facilities in the two communities. These data cover services received between 1997 and 2003. The analysis focuses on the year following study entry.

PRINCIPAL FINDINGS

Between-site differences in expenditures reflect complex between-site differences in the timing of service use. In particular, children at the demonstration stayed in treatment longer but were less likely to return for treatment later. In contrast, children at the comparison site experienced substantially less continuity of care. Costs per day of treatment within an episode were comparable at the two sites.

CONCLUSIONS

Reward renewal models offer a promising means for integrating research on service episodes and the dynamics of service use with that on health care expenditures.

Pharmaceutical cost management and access to psychotropic drugs: the U.S. context

In recent years, prescription drug expenditures in the United States have increased rapidly. In 2003, spending on prescription medications totaled $179.2 billion dollars, or approximately 11% of national health expenditures [Smith, C., Cowan, C., Sensenig, A., Catlin, A., the Health Accounts Team. (2005). Health spending growth slows in 2003. Health Affairs, 24 (1) 185-194]. In response to rapid increases in prescription drug expenditures, both public and private payers of health care services have adopted strategies to try to contain drug costs, including drug formularies, prior authorization programs, cost sharing and utilization management. In this paper, I provide a background on prescription drug spending trends, financing, and access to medications; describe some of the tools used most commonly to manage prescription drug utilization; present results from the literature on the impact of these tools; and discuss some implications of this information for the new Medicare prescription drug benefit to be implemented in 2006 as well as for future prescription drug innovation.

Provider type and depression treatment adequacy

We investigate the effect of initial provider (psychiatrist versus primary care physician or non-physician mental health specialist) on the adequacy of subsequent treatment for persons with depression. Our data are from MarketScan, a medical and pharmacy insurance claims database, which we use to estimate models of the likelihood of treatment for depression and the likelihood that any anti-depression treatments received are adequate. Patients initially seeing psychiatrists are most likely to receive adequate treatment. Provider type has a statistically and medically significant effect on whether any treatment occurs but a smaller effect on treatment adequacy among treated patients. Our results show the importance of provider type in treatment patterns, but the effects on patient outcomes are yet to be determined definitively.

Stakeholder perspectives on public managed behavioral care in Massachusetts

The 2003 survey of Massachusetts behavioral health providers, as well as conference presentations by other key stakeholders, demonstrate continuing high ratings for the Massachusetts Behavioral Health Program. Key issues facing the program include improving integration, state funding cutbacks, movement into performance and outcomes measurement, and concerns about continuing stigma of mental illness. These issues are prevalent in other states that can benefit from the studies and perspectives of the Massachusetts experience.

Incentives in a Medicaid carve-out: impact on children with special health care needs

OBJECTIVE

To evaluate whether a specialty care payment "carve-out" from Medicaid managed care affects caseloads and expenditures for children with chronic conditions.

DATA SOURCE

Paid Medicaid claims in California with service dates between 1994 and 1997 that were authorized by the Title V Children with Special Health Needs program for children under age 21.

STUDY DESIGN

A natural experiment design evaluated the impact of California's Medicaid managed care expansion during the 1990s, which preserved fee-for-service payment for certain complex medical diagnoses. Outcomes in time series regression include Title V program participation and expenditures. Multiple comparison groups include children in managed care counties who were not mandated to enroll, and children in nonmanaged care counties.

DATA COLLECTION/EXTRACTION METHODS

Data on the study population were obtained from the state health department claims files and from administrative files on enrollment and managed care participation.

PRINCIPAL FINDINGS

The carve-out policy increased the number of children receiving Title V-authorized services. Recipients and expenditures for some ambulatory services increased, although overall expenditures (driven by inpatient services) did not increase significantly. Cost intensity per Title V recipient generally declined.

CONCLUSIONS

The carve-out policy increased identification of children with special health care needs. The policy may have improved children's access to prevailing standards of care by motivating health plans and providers to identify and refer children to an important national program.

Mental health policy and psychotropic drugs

The pace of innovation in psychotropic drugs has been rapid over the past 15 years. There also have been unprecedented increases in spending on prescription drugs generally and psychotropic medications specifically. Psychotropic medications are playing a more central role in treatment. They also are receiving close scrutiny from health insurers, state budget makers, and ordinary citizens. Public policy actions regarding prescription drugs have the potential to significantly affect clinical care for mental disorders, the costs of this care to individuals and society at large, and the prospects for future scientific advances. This article outlines the policy issues related to psychotropic drugs with respect to their role in determining access to mental health treatment and the cost and quality of mental health care.

Quality of care measures for the treatment of bipolar disorder

The staff of the American Psychiatric Association (APA), the American Psychiatric Institute for Research and Education (APIRE), and a national panel of experts in bipolar disorder and practice guideline development have collaborated to generate a set of quality of care indicators for the pharmacologic and psychosocial treatment of bipolar disorder. The indicators were derived from APA's evidence-based Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2002 (1) and the Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder, 2000 (2) These quality indicators can be used for quality monitoring, benchmarking, and quality improvement efforts across health plans, systems of care, and health care providers to improve quality and outcomes of care for patients with bipolar disorder.

QUALITY-CONSTANT "PRICES" FOR THE ONGOING TREATMENT OF SCHIZOPHRENIA: AN EXPLORATORY STUDY*

Health care expenditures have been increasing sharply in the last ten years, with spending on mental health disorders being particularly prominent. Over the same time period, a number of new antipsychotic medications have been added to the armamentarium for treatment of persons diagnosed with schizophrenia. Due in part to the sharply increased expenditures by Medicaid on mental health disorders such as schizophrenia, controversies have arisen as to the use of these more costly innovative medications, particularly their impact on the annualized cost of treating patients.Using Medicaid data on 12,864 person years from two counties in Florida over the 1994-95 to 1999-2000 time period, in this study we address three issues: (i) On a per person year basis, what is happening over time to the mental health-related costs of treating schizophrenia? (ii) How is the composition and quality of care changing over time? and (iii) Holding quality of care constant, on a per person year basis, by how much are the costs for the ongoing treatment of schizophrenia changing?We find that unadjusted for changes in quality of care over time, the annualized costs for the ongoing treatment of schizophrenia per person have increased about 0.5% per year. The composition of treatments for schizophrenia has changed substantially over this six-year time period, toward more intensive use of atypical antipsychotics, and away from psychosocial treatments. Holding treatment quality type and patient characteristics constant over time, mean treatment costs have fallen about 5.5% per year between 1994-1995 and 1999-2000.

Managing Psychotropic Drug Costs: Will Formularies Work?

Payers of pharmaceutical benefits are increasingly turning to drug formularies in an attempt to control rising pharmacy costs, including those for psychotropic drugs. In this paper I examine several issues that policymakers should consider when addressing formulary design for psychotropic drugs: heterogeneity within mental health disorders and limited information about treatment effectiveness for individual patients; the potential for plans to try to use formularies to avoid adverse selection and implications for psychotropic coverage; the interaction of Medicaid formulary policy and manufacturers' incentives for psychotropic innovation; and incentives created by mental health institutions that decrease formularies' potential effectiveness in controlling psychotropic drug costs.