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PubMed1979

The relationship between utilization of mental health and somatic health services among low income enrolees in two provider plans.

Mental health services were included in comprehensive benefits available with no out-of-pocket expenses to enrollees in the Seattle Prepaid Health Care Project. This study was designed to examine the characteristics of users as compared to nonusers of mental health services and to examine the possibility of lower use of somatic health services attributable to the availability of mental health services. Two enrollee groups were studied: one group included enrollees with at least one mental health service (MH-U) and the other included those with some somatic utilization but without mental health utilization (MH-NU). Results indicated that mental health users were different from nonusers based on sociodemographic, health status, and prior utilization measures. Further, the mental health utilizers consumed more somatic services than other enrollees, even controlling for background variables. The visit and admission rates for the MH-U group were 2.4 times that of the MH-NU group, and total inpatient and outpatient costs were three times as high. On all three comparisons, approximately 60 per cent of the difference was accounted for by mental health utilization and by differences in sociodemographic and health status characteristics. The remaining 40 per cent could not be explained, but there is a suggestion that the higher utilization occurred for conditions where medical care is discretionary.

Adolescent↗
PubMed1981

A comparison of mental health costs and utilization under three insurance models.

Published reports on utilization and costs of mental health services provided under three insurance models (prepaid, cost-financed and indemnity) reveal consistently greater utilization of outpatient services, lower overall inpatient utilization and comparable costs among prepaid plans in contrast with other two models. The present study suggests that prepaid plans, by facilitating the use of specialty mental health services by a substantially greater proportion of their membership than the other two models, come closer to serving their total population in need as projected by epidemiologic studies. While the data on cost containment are less clear, prepaid plans show a shift in costs away from inpatient and toward outpatient care. However, because of the possibility of bias of differences in population served, treatment philosophy and benefits offered, conclusions drawn from these findings must be tentative until a prospective comparison controlling for these differences can be carried out.

Costs and Cost Analysis↗
PubMed1986

Sociodemographic factors and the use of outpatient mental health services.

What are the effects of sociodemographic factors on the use of outpatient mental health services when different demographic groups have identical health insurance coverage? The authors answer this question using data from the Rand Health Insurance Experiment. Health insurance was randomly assigned to families representative of the nonaged, noninstitutionalized civilian population in six U.S. sites. Income has no significant total effect on use when all income groups have the same coverage. When the effects of variables correlated with socioeconomic status are removed, users with higher socioeconomic status are significantly more likely to choose a mental health specialist rather than only general medical providers for their mental health care (P less than 0.05); among those who visit mental health specialists, those with higher socioeconomic status incur significantly greater expenses (P less than 0.10). Women use significantly more mental health services than men (P less than 0.05), who in turn use significantly more mental health services than children (P less than 0.05), even after controlling for demographic factors, health status, and insurance coverage. Similarly, there are large differences (roughly sixfold) by site in outpatient mental health expenses even when all sites have identical coverage.

Adolescent↗
PubMed1986

A comparison of the effects of sociodemographic factors and health status on use of outpatient mental health services in HMO and fee-for-service plans.

The authors compared the effects of age, sex, socioeconomic status, and mental and physical health status on the use of outpatient mental health services in one well-established health maintenance organization (HMO) and in fee-for-service plans. In the Seattle site of the Rand Health Insurance Study (HIS), families were randomly assigned to HMO or fee-for-service coverage. Adults incur much greater expense for outpatient mental health services than children in both an HMO and a fee-for-service plan with identical coverage (i.e., free care). However, the difference in use between adults and children is significantly greater for the fee-for-service plan than the HMO (P less than 0.01). Similarly, education has significantly greater effects on use for the fee-for-service than the HMO plan. Increased income has a significant negative effect on use in both the HMO and fee-for-service plans. Mental and physical health status have similar large effects on use in both fee-for-service and HMO plans.

Adult↗
PubMed1987

Ownership and performance: the case of outpatient mental health clinics.

Policy analysts and researchers have been concerned with the growth and impact of for-profit institutions providing health care services. Research results to date have been mixed on the effect of ownership on quality and cost to payers. Equivocal findings may be due, in part, to measurement limitations inherent in facility-level data. This study reports results from a homogeneously insured population receiving outpatient mental health care at proprietary and nonprofit clinics. Data are claims on behalf of 30,000 covered individuals served at 223 clinics. Controls for case mix and other variables permit isolation of the impact of form of ownership. Using regression analysis, the authors find that payments to proprietary clinics exceeded payments to private nonprofit clinics by 27%, public clinics by 19%, and religious clinics by 17%. All differences were significant. This finding suggests that proprietary clinics are on average more commercially oriented than nonprofit facilities.

Health Facilities, Proprietary↗
PubMed1992

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.

Adult↗
PubMed1993

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.

Adolescent↗
PubMed2001

Effects of cost-containment strategies within managed care on continuity of the relationship between patients with depression and their primary care providers.

BACKGROUND: Continuity of the relationship between patients and primary care providers (PCPs) is an important component of care from the consumer perspective that may be affected by variation in cost containment strategies within managed care. OBJECTIVE: To evaluate the effects of cost containment strategies on the continuity of the relationship between their patients with depression and their PCPs. DESIGN: Observational analysis of a 2-year panel of depressed patients who participated in a quality improvement intervention trial in 46 managed care practices. PARTICIPANTS: One thousand two hundred four patients with current depression who enrolled in a longitudinal study, completed the baseline survey, and were followed for 2 years. MAIN MEASURES: The dependent variable is probability of continuing the relationship between patients and their PCPs; explanatory variables include individual patient mental health benefits and cost-sharing, individual provider financial incentives, supply-side managed care policies, and patient ratings of the care received. RESULTS: The average duration of the patient-PCP relationship was significantly longer among depressed patients who initially had less generous benefits for specialty care (higher copays, P = 0.02 and fewer visits covered, P = 0.002) and for patients whose PCPs received a performance-based salary bonus from a risk pool (P = 0.07). CONCLUSIONS: For depressed patients, cost containment strategies, such as limits on specialty benefits and presence of clinician bonus payments typically used within managed care may increase, rather than decrease, PCP continuity. Whether increased PCP continuity is a desirable outcome depends on whether health care systems can provide high quality primary care and this merits further study.

Adult↗
PubMed2002

Knowledge of health care benefits among patients with depression.

OBJECTIVE: To evaluate the accuracy of patient self-reports of health care insurance coverage relative to actual health care benefits and to explore patient predictors of accuracy among patients with depression. METHODS: Data were analyzed from 767 patients with current depressive symptoms and disorder who completed a self-report mail survey that included questions about health insurance and for whom we also obtained actual health care benefits records. Percentage agreement and kappa statistics were calculated for different types of benefits (medical visit, pharmacy and mental health visit copays, and mental health visit limits), and we used multivariate analysis to examine predictors of accuracy. RESULTS: Accuracy of self-reports relative to administrative data were good for measures of medical visits and prescription copays (kappa = 0.79 and 0.64), but less accurate for measures of mental health benefits (kappa = 0.19 for copays and 0.40 for visit coverage). Recent use of health care services (past 6 months) increased the accuracy of medical benefits but not of mental health benefits. Inaccuracy of mental health benefits was in the direction of patients perceiving more generous coverage than was actually available to them. Men and those with greater wealth were more knowledgeable about their medical benefits. Those from a nonminority ethnic group, who were less satisfied, and were less sick had better knowledge about their mental health benefits. CONCLUSIONS: Agreement between self-reports and actual benefits was stronger for general medical services than for mental health care. Background, experience, and sickness lead to more accurate recall of insurance information.

Adult↗
PubMed1991

Employee assistance program compliance: impact of contrasting insurance coverage.

Employee assistance programs are offered by employers to assist employees with personal problems through professional evaluation of the problem and referral to an appropriate treatment source. Although some research has been conducted to document the effect of these programs on such variables as absenteeism and disciplinary action, little information is available regarding compliance with clinical recommendations, ie, initiating and remaining in prescribed treatment. The present study evaluated the effect of two different rates of insurance coverage for outpatient mental health services offered by two comparable blue-collar organizations. Employees from the organization with a higher rate of payment were significantly more likely to initiate treatment and to remain in treatment longer. This outcome was not accounted for by demographic differences between the groups or by differences in diagnostic categories or treatment approaches. Implications of this finding are discussed as well as the utility of an employee assistance program to prepare employees for treatment.

Adult↗
PubMed2006

Expanded mental health benefits and outpatient depression treatment intensity.

BACKGROUND: The justification for higher cost-sharing for behavioral health treatment is its greater price sensitivity relative to general healthcare treatment. Despite this, recent policy efforts have focused on improving access to behavioral health treatment. OBJECTIVES: We measured the effects on outpatient treatment of depression of a change in mental health benefits for employees of a large U.S.-based corporation. RESEARCH DESIGN: The benefit change involved 3 major elements: reduced copayments for mental health treatment, the implementation of a selective contracting network, and an effort to destigmatize mental illness. Claims data and a difference-in-differences methodology were used to examine how the benefit change affected outpatient treatment of depression. SUBJECTS: Subjects consisted of 214,517 employee-years of data for individuals who were continuously enrolled for at least 1 full year at the intervention company and 96,365 employee-years in the control group. MEASURES: We measured initiation into treatment of depression and the number of outpatient therapy visits. RESULTS: The benefit change was associated with a 26% increase in the probability of initiating depression treatment. Conditional on initiating treatment, patients in the intervention company received 1.2 additional (P < 0.001) outpatient mental health treatment visits relative to the control group. CONCLUSIONS: Our results suggest that the overall effect of the company's benefit change was to significantly increase the number of outpatient visits per episode of treatment conditional on treatment initiation.

Adult↗
PubMed2006

The effects of state parity laws on the use of mental health care.

OBJECTIVE: We used a quasiexperimental research design to measure the effect of state parity laws on the use of mental health care in the past year. METHODS: We pooled cross-sectional data from the 2001, 2002, and 2003 National Surveys on Drug Use and Health. Our sample included 83,531 adults 18 years of age or over with private health insurance stratified by the level of mental and emotional distress experienced in the worst month of the past year. We used a state and year-fixed effects approach to measure the effect of parity. Similar to a difference-in-difference analysis, the effect of parity was measured by comparing pre-/postchanges in mental health service use within states that switched active parity status to changes in service use within states that did not change parity status in the same calendar year. For each subgroup, we report predictions of the percentage point change in any mental health care use, prescription drug use, and outpatient care use resulting from parity laws. RESULTS: Depending on the time window used to define active parity status, we found that parity increased the probability of using any mental health care in the past year by as much as 1.2 percentage points (P<0.01) for the lower distress group and by as much as 1.8 percentage points (P<0.05) in the middle distress group. We found no statistically significant changes in service use for the upper distress group. Whether measured differences were attributable to changes in the use of prescription drug or outpatient care also depended on the definition of active parity status. CONCLUSIONS: Overall, the results of this study suggest that state parity laws succeeded in expanding access to mental health care for those with relatively mild mental health problems.

Adolescent↗
PubMed2007

Outpatient mental health utilization among commercially insured individuals: in- and out-of-network care.

OBJECTIVE: This study examined the rates and correlates of out-of-network outpatient mental health specialty care. RESEARCH DESIGN: Using administrative data from a large insurer, we examine the frequency of out-of-network utilization, analyze demographic and clinical characteristics of individuals receiving out-of-network care, and examine the types of service provided out-of-network. RESULTS: Out-of-network outpatient mental health care was received by 15.4% of adults who used outpatient mental health services, with 11.8% of adult outpatient mental health users receiving only out-of-network care and 3.6% receiving both in-network and out-of-network care. Out-of-network users received significantly more outpatient mental health care than individuals receiving only in-network mental health care. Rates of out-of-network psychotherapy services were substantially greater than for other commonly provided mental health services. CONCLUSION: A significant number of patients covered under this insurer received their outpatient mental health care out-of-network. This is most pronounced for individuals receiving psychotherapy. Further information is needed to improve our understanding of who seeks care from out-of-network providers and why as well as the effect of such care on clinical outcomes.

Adolescent↗
PubMed2002

Rationing mental health care: parity, disparity, and justice.

Recent policy debates in the US over access to mental health care have raised several philosophically complex ethical and conceptual issues. The defeat of mental health parity legislation in the US Congress has brought new urgency and relevance to theoretical and empirical investigations into the nature of mental illness and its relation to other forms of sickness and disability. Manifold, nebulous, and often competing conceptions of mental illness make the creation of coherent public policy exceedingly difficult. Referencing a variety of approaches to ethical reflection on health care, and drawing from the empirical literature on therapeutic efficacy and economic efficiency, we argue that differential rationing, 'disparity,' is unjustifiable.

Ethical Analysis↗
PubMed2002

Mental health costs and access under alternative capitation systems in Colorado.

OBJECTIVE: To examine service cost and access for persons with severe mental illness under Medicaid mental health capitation payment in Colorado. Capitation contracts were made with two organizational models: community mental health centers (CMHCs) that manage and deliver services (direct capitation [DC]) and joint ventures between CMHCs and a for-profit managed care firm (managed behavioral health organization, [MBHO]) and compared to fee for service (F.F.S.). DATA SOURCES/STUDY SETTING: Both primary and secondary data were collected for the year prior to the new financing policy and the following two years (1995-1998). STUDY DESIGN: A stratified random sample of 522 severely mentally ill subjects was selected from comparable geographic areas within the capitated and FFS regions of Colorado. Major variables include service cost, utilization, and access (probability of service use) derived from secondary claims data, subject reported access collected at six-month intervals, and baseline outcomes (symptoms, functioning, and quality of life). PRINCIPAL FINDINGS: In comparison to the FFS area, cost per person was reduced in the capitated areas in each of the two years following implementation. By the end of year two, cost per person was reduced by two-thirds in the MBHO areas and by one-fifth in the DC areas. Reductions in access were found for both capitated areas, although reductions in utilization for those receiving service were found only in the MBHO model. CONCLUSIONS: Medicaid mental health capitation in Colorado resulted in cost reducing service changes for persons with severe mental illness. Assessment of outcome change is necessary to identify cost effectiveness.

Adolescent↗
PubMed2002

Two-year outcomes of fee-for-service and capitated medicaid programs for people with severe mental illness.

OBJECTIVE: To examine the effects of two models of capitation on the clinical outcomes of Medicaid beneficiaries in the state of Colorado. DATA SOURCE: A large sample of adult, Medicaid beneficiaries with severe mental illness drawn from regions where capitation contracts were (1) awarded to local community mental health agencies (direct capitation), (2) awarded to a joint venture between local community mental health agencies and a large, private managed behavioral health organization, and (3) not awarded and care continued to be reimbursed on a fee-for-service basis. STUDY DESIGN: The three samples were compared on treatment outcomes assessed over 2 years (total n = 591). DATA COLLECTION METHODS: Study participants were interviewed by trained, clinical interviewers using a standardized protocol consisting of the GAF, BPRS, QOLI, and CAGE. PRINCIPAL FINDINGS: Outcomes were comparable across most outcome measures. When outcome diffrences were evident, they tended to favor the capitation samples. CONCLUSIONS: Medicaid capitation in Colorado does not appear to have negatively affected the outcomes of people with severe mental illness during the first 2 years of the program. Furthermore, the type of capitation model was unrelated to outcomes in this study.

Adolescent↗