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Reif S, Torres ME, Horgan CM, Merrick EL. Characteristics of practitioners in a private managed behavioral health plan. BMC Health Serv Res 2012; 12:283. [PMID: 22929051 PMCID: PMC3577445 DOI: 10.1186/1472-6963-12-283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 08/10/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about the practitioners in managed behavioral healthcare organization (MBHO) networks who are treating mental and substance use disorders among privately insured patients in the United States. It is likely that the role of the private sector in treating behavioral health will increase due to the recent implementation of federal parity legislation and the inclusion of behavioral health as a required service in the insurance exchange plans created under healthcare reform. Further, the healthcare reform legislation has highlighted the need to ensure a qualified workforce in order to improve access to quality healthcare, and provides an additional focus on the behavioral health workforce. To expand understanding of treatment of mental and substance use disorders among privately insured patients, this study examines practitioner types, experience, specialized expertise, and demographics of in-network practitioners providing outpatient care in one large national MBHO. METHODS Descriptive analyses used 2004 practitioner credentialing and other administrative data for one MBHO. The sample included 28,897 practitioners who submitted at least one outpatient claim in 2004. Chi-square and t-tests were used to compare findings across types of practitioners. RESULTS About half of practitioners were female, 12% were bilingual, and mean age was 53, with significant variation by practitioner type. On average, practitioners report 15.3 years of experience (SD = 9.4), also with significant variation by practitioner type. Many practitioners reported specialized expertise, with about 40% reporting expertise for treating children and about 60% for treating adolescents. CONCLUSIONS Overall, these results based on self-report indicate that the practitioner network in this large MBHO is experienced and has specialized training, but echo concerns about the aging of this workforce. These data should provide us with a baseline of practitioner characteristics as we enter an era that anticipates great change in the behavioral health workforce.
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Affiliation(s)
- Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management Brandeis University, Waltham, MA, USA
| | - Maria E Torres
- Institute for Behavioral Health, Heller School for Social Policy and Management Brandeis University, Waltham, MA, USA
| | - Constance M Horgan
- Institute for Behavioral Health, Heller School for Social Policy and Management Brandeis University, Waltham, MA, USA
| | - Elizabeth L Merrick
- Institute for Behavioral Health, Heller School for Social Policy and Management Brandeis University, Waltham, MA, USA
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Stefos T, Burgess JF, Cohen JP, Lehner L, Moran E. Dynamics of the mental health workforce: investigating the composition of physicians and other health providers. Health Care Manag Sci 2012; 15:373-84. [PMID: 22723031 DOI: 10.1007/s10729-012-9203-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 05/31/2012] [Indexed: 11/25/2022]
Abstract
We evaluate how changes to mental health workforce levels, composition, and degree of labor substitution, may impact typical practice output. Using a generalized Leontief production function and data from 134 U.S. Department of Veterans Affairs (VA) mental health practices, we estimate the q-complementarity/q-substitutability of mental health workers. We look at the entire spectrum of mental health services rather than just outpatient or physician office services. We also examine more labor types, including residents, than previous studies. The marginal patient care output contribution is estimated for each labor type as well as the degree to which physicians and other mental health workers may be substitutes or complements. Results indicate that numerous channels exist through which input substitution can improve productivity. Seven of eight labor and capital inputs have positive estimated marginal products. Most factor inputs exhibit diminishing marginal productivity. Of 28 unique labor-capital pairs, 17 are q-complements and 11 are q-substitutes. Complementarity among several labor types provides evidence of a team approach to mental health service provision. Our approach may serve to better inform healthcare providers regarding more productive mental health workforce composition both in and outside of VA.
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Affiliation(s)
- Theodore Stefos
- VHA Office of Productivity, Efficiency and Staffing, Department of Veterans Affairs (VA), VAMC (518/MSG/VISN1/Building 61), 200 Springs Road, Bedford, MA 01730, USA.
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Fleury MJ, Grenier G, Bamvita JM, Perreault M, Caron J. Determinants of the utilization of diversified types of professionals for mental health reasons in a Montreal (Canadian) catchment area. Glob J Health Sci 2012; 4:13-29. [PMID: 22980229 PMCID: PMC4776932 DOI: 10.5539/gjhs.v4n3p13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 03/07/2012] [Accepted: 02/24/2012] [Indexed: 11/30/2022] Open
Abstract
The study was designed to identify factors associated with the diversity of professionals consulted by 212 individuals affected by at least one mental disorder in the past 12 months in a Montreal catchment area. For inclusion in the study, participants had to be aged 15 to 65 and reside in the study zone. A comprehensive set of variables were analyzed in accordance with the Andersen's behavioural model of health service use. General practitioners, psychiatrists, and psychologists were the main professionals consulted in this study. Having post-secondary education, more than a single mental disorder, excellent relationships with neighbours, and (marginally) being a lifelong victim of violence were associated with higher numbers of professionals consulted. As this study highlights the large number of diversified professionals consulted for reason of mental disorders, shared care initiatives may prove beneficial. Greater effort could also be made in increasing services toward those deemed more vulnerable.
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Reif S, Horgan C, Torres M, Merrick E. Economic grand rounds: types of practitioners and outpatient visits in a private managed behavioral health plan. Psychiatr Serv 2010; 61:1066-8. [PMID: 21041341 PMCID: PMC3848051 DOI: 10.1176/ps.2010.61.11.1066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Types of privately insured outpatient treatment provided by in-network practitioners were examined in a national managed behavioral health care organization to consider how practitioner type and expertise are related to diagnoses of mental disorders, substance use disorders, or both. Using 2004 practitioner credentialing, patient enrollment, and claims data, the investigators found that two-thirds of claims for psychiatrists involved medication management and two-thirds also involved psychotherapy (an overlap of about 30%). Most patients with substance use disorders saw practitioners who had specialized alcohol or drug disorder training. Claims for patients with more complex co-occurring mental and substance use disorders indicate utilization of appropriately qualified practitioners with substantial experience on average.
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Affiliation(s)
- Sharon Reif
- Heller School for Social Policy and Management, Brandeis University, 415 South St., MS035, Waltham, MA 02454, USA.
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Ghaemi SN. Toward a Hippocratic psychopharmacology. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2008; 53:189-96. [PMID: 18441665 DOI: 10.1177/070674370805300309] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To provide a conceptual basis for psychopharmacology. METHOD This review compares contemporary psychopharmacology practice with the Hippocratic tradition of medicine by examining the original Hippocratic corpus and modern interpretations (by William Osler and Oliver Wendell Holmes). RESULTS The Hippocratic philosophy is that only some, not all, diseases should be treated and, even then, treatments should enhance the natural healing process, not serve as artificial cures. Hippocratic ethics follow from this philosophy of disease and treatment. Two rules for Hippocratic medicine are derived from the teachings of Osler (treat diseases, not symptoms) and Holmes (medications are guilty until proven innocent). The concept of a diagnostic hierarchy is also stated explicitly: Not all diseases are created equal. This idea helps to avoid mistaking symptoms for diseases and to avoid excessive diagnosis of comorbidities. Current psychopharmacology is aggressive and non-Hippocratic: symptom-based, rather than disease oriented; underemphasizing drug risks; and prone to turning symptoms into diagnoses. These views are applied to bipolar disorder. CONCLUSIONS Contemporary psychopharmacology is non-Hippocratic. A proposal for moving in the direction of a Hippocratic psychopharmacology is provided.
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Affiliation(s)
- S Nassir Ghaemi
- Bipolar Disorder Research Program, Emory University, Atlanta, Georgia, USA.
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Kishi Y, Kathol RG, McAlpine DD, Meller WH, Richards SW. What should non-US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s. Psychiatry Clin Neurosci 2006; 60:261-70. [PMID: 16732740 DOI: 10.1111/j.1440-1819.2006.01500.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic-related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health-care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health-care spending through independent management, starting with diagnostic procedure code or diagnostic-related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.
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Affiliation(s)
- Yasuhiro Kishi
- Department of Psychiatry, University of Minnesota, Minnesota, USA.
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Domino ME, Huskamp H. Does provider variation matter to health plans? JOURNAL OF HEALTH ECONOMICS 2005; 24:795-813. [PMID: 15960996 DOI: 10.1016/j.jhealeco.2005.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2004] [Revised: 01/31/2005] [Accepted: 01/31/2005] [Indexed: 05/03/2023]
Abstract
Variance in treatments prescribed by an individual provider may indicate higher quality through better matching of patients to treatments or it may indicate uncertainty about the healthcare production function. It is unknown how health plans respond to provider-level treatment variation. We use a model drawn from the portfolio selection literature, which examines the choice among risky assets, or in this case, providers with heterogeneous treatment variance. We test this model on data from a behavioral healthcare vendor that exercises some control over provider selection. We find little evidence that the plan responds to provider-level variance.
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Affiliation(s)
- Marisa Elena Domino
- Department of Health Policy and Administration, The University of North Carolina at Chapel Hill, 1104G McGavran-Greenberg Hall, CB #7411, Chapel Hill, NC 27599-7411, USA.
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Patterns of Medical Resource and Psychotropic Medicine Use Among Adult Depressed Managed Behavioral Health Patients. J Behav Health Serv Res 2004. [DOI: 10.1097/00075484-200401000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Azocar F, McCarter LM, Cuffel BJ, Croghan TW. Patterns of medical resource and psychotropic medicine use among adult depressed managed behavioral health patients. J Behav Health Serv Res 2004; 31:26-37. [PMID: 14722478 DOI: 10.1007/bf02287336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Medical and pharmacy utilization patterns were examined among 782 depressed patients seen by independent clinicians through a Managed Behavioral Health Organization using behavioral, medical and pharmacy claims spanning 2 years. Two-thirds received psychiatric care in the medical and mental health sector concurrently, 43% had comorbid medical disorders, 61% received psychotropic medications, and 54% were on antidepressants. Fewer depressed medically comorbid patients used medical services while in mental health treatment than before or after treatment, while the per patient costs remained the same. For those with chronic conditions, medical utilization and costs remained the same. A quarter of depressed patients received mental health treatment before seeing a mental health specialist, and a quarter remained in treatment in the medical sector after treatment in the mental health sector. Despite increases in mental health services access made available through managed behavioral health organizations, patients continue receiving mental health treatment in the medical sector.
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Affiliation(s)
- Francisca Azocar
- Behavioral Health Sciences Department, United Behavioral Health, 425 Market St, 27th Floor, San Francisco, CA 94105, USA.
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Grembowski DE, Martin D, Patrick DL, Diehr P, Katon W, Williams B, Engelberg R, Novak L, Dickstein D, Deyo R, Goldberg HI. Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms. J Gen Intern Med 2002; 17:258-69. [PMID: 11972722 PMCID: PMC1495032 DOI: 10.1046/j.1525-1497.2002.10321.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms. DESIGN Prospective cohort study. SETTING Offices of 261 primary physicians in private practice in Seattle. PATIENTS Patients (N = 17,187) were screened in waiting rooms, enrolling 1,336 adults with depressive symptoms. Patients (n = 942) completed follow-up surveys at 1, 3, and 6 months. MEASUREMENTS AND RESULTS For each patient, the intensity of managed care was measured by the managedness of the patient's health plan, plan benefit indexes, presence or absence of a mental health carve-out, intensity of managed care in the patient's primary care office, physician financial incentives, and whether the physician read or used depression guidelines. Access measures were referral and actually seeing a mental health specialist. Outcomes were the Symptom Checklist for Depression, restricted activity days, and patient rating of care from primary physician. Approximately 23% of patients were referred to mental health specialists, and 38% saw a mental health specialist with or without referral. Managed care generally was not associated with a reduced likelihood of referral or seeing a mental health specialist. Patients in more-managed plans were less likely to be referred to a psychiatrist. Among low-income patients, a physician financial withhold for referral was associated with fewer mental health referrals. A physician productivity bonus was associated with greater access to mental health specialists. Depressive symptom and restricted activity day outcomes in more-managed health plans and offices were similar to or better than less-managed settings. Patients in more-managed offices had lower ratings of care from their primary physicians. CONCLUSIONS The intensity of managed care was generally not associated with access to mental health specialists. The small number of managed care strategies associated with reduced access were offset by other strategies associated with increased access. Consequently, no adverse health outcomes were detected, but lower patient ratings of care provided by their primary physicians were found.
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Affiliation(s)
- David E Grembowski
- Center for Cost and Outcomes Research, Department of Health Services, University of Washington, Seattle, Wash 98195-7660, USA.
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Abstract
An estimated 6.2% of children in the United States satisfy the criteria for a depression diagnosis, but approximately half of this group do not receive necessary treatment. Thus it is important to consider potential barriers to use through service system finance. This article reviews three major types of changes affecting access: parity legislation, managed care, and public contracting. How these developments will affect children with depression and manic depression (DMD) is unclear. To better understand the potential effects on children with DMD, this review uses new data from the Medical Expenditure Panel Survey to describe the service use patterns of this population. These children have higher levels of expenditures, higher rates of inpatient use, and higher rates of Medicaid payment than do other children with mental health diagnoses; they also are overrepresented among the costliest cases of mental illness in children. Children with DMD pay a relatively low out-of-pocket share, suggesting that parity efforts focusing only on copayments and deductibles will have little effect on the absolute out-of-pocket burden for these children. Because children with DMD are overrepresented among high utilizers of health services, health care rationing arrangements or techniques, such as utilization review and capitation, may place this population at particular risk.
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Affiliation(s)
- S Glied
- Division of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York 10032, USA
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Sturm R. Tracking changes in behavioral health services: how have carve-outs changed care? J Behav Health Serv Res 1999; 26:360-71. [PMID: 10565097 DOI: 10.1007/bf02287297] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This special issue of the Journal of Behavioral Health Services & Research on mental health carve-outs brings together some of the latest research on recent policy and market changes affecting behavioral health services. This introductory article provides background information about carve-outs and the managed behavioral health care industry. This article also reviews prior research in the mental health carve-out field.
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Affiliation(s)
- R Sturm
- RAND Corporation, Santa Monica, CA 90401, USA.
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Stein B, Reardon E, Sturm R. Substance abuse service utilization under managed care: HMOs versus carve-out plans. J Behav Health Serv Res 1999; 26:451-6. [PMID: 10565105 DOI: 10.1007/bf02287305] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Managed behavioral health care organizations are increasingly managing Americans' substance abuse by using carve-outs, but little information is available about how this has affected service utilization and costs when compared to HMOs. One employer's claims for substance abuse services delivered under a carve-out arrangement are compared to prior HMO claims information. Under the carve-out arrangement, inpatient and outpatient service utilization are found to decrease, but intermediate service utilization dramatically increases. Costs per unit service decrease for all services. The pattern of changes is different from that seen for mental health services, suggesting that different factors may be applicable to substance abuse services.
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Affiliation(s)
- B Stein
- RAND Corporation, Santa Monica, CA 90401, USA.
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