Cost-sharing and the use of general medical physicians for outpatient mental health care.

Many patients with emotional disorders receive their mental health care from general medical physicians. In this article, we examine differences in costs and style between mental health care delivered by mental health specialists and that provided by general medical physicians, and the sensitivity to insurance of the patient's choice of mental health care provider. We use data from a randomized trial of cost-sharing, the RAND Health Insurance Experiment. Even when all outpatient mental health care was free (up to 52 visits a year), one-half of the users of outpatient mental health services visited general medical providers only. This half accounted for only 5 percent of outpatient mental health care expenditures, because the treatment delivered by general medical providers was much less intensive than that delivered by mental health specialists. Mental health status, at enrollment, was similar for those who received their mental health care from either provider group. Despite the large difference in cost of care, the choice of provider (mental health specialist versus general medical provider) was not sensitive to the generosity of insurance.     

Making room for mental health in the medical home

Discussions of health care reform emphasize the need for coordinated care, and evidence supports the effectiveness of medical home and integrated delivery system models. However, mental health often is left out of the discussion. Early intervention approaches for children and adolescents in primary care are important given the increased rates of detection of mental illness in youth. Most adults also receive treatment for mental illness from nonspecialists, underscoring the role for mental health in medical home models. Flexible models for coordinated care are needed for people with serious mental illness, who have high rates of comorbid medical problems. Programs implemented in the New York State public mental health system are examples of efforts to better coordinate medical and mental health services.     

Help seeking for mental health problems among Mexican Americans

This study uses data from a household survey (Mexican American Prevalence and Services Study; MAPSS) of 3,000 respondents in Fresno County, California, to 1) contrast use across multiple sectors of care among immigrant and U.S. born Mexican Americans with recent psychiatric disorders, 2) contrast multiple provider utilization patterns, and 3) identify specific factors associated with the use of mental health specialty and general medical sectors. Immigrants and U.S. born disproportionately used the general medical sector for treating mental health problems. The U.S. born were more likely to use family physicians and counselors than were immigrants, and neither relied heavily upon informal network providers to treat psychiatric disorders. A comparison of patterns showed that most people with a recent disorder used a combination of providers. The logistic regression analyses showed that knowing where to find a provider increased the likelihood of specialty mental health use by an odds ratio (O.R.) of 4.68. Private insurance increased use of mental health providers, O.R. = 3.76. Public insurance availability did not increase mental health provider use, suggesting that other factors were linked to use of mental health specialty care. Public insurance did increase medical sector care for psychiatric problems, O.R. = 2.57. Poor self-rated mental health status was primarily associated with use of physicians by U.S. born (O.R. = 5.39). Severe mental health impairment increased use of both general medical (O.R. = 5.54) and specialty mental health (O.R. = 5.1) providers. These results point out that eligibility for public insurance is a necessary but not sufficient status to increase mental health sector care among immigrants, and education and more effective referral from other sectors are needed to encourage use of these services.     

Mental health/medical care cost offsets: opportunities for managed care

Health services researchers have long observed that outpatient mental health treatment sometimes leads to a reduction in unnecessary or excessive general medical care expenditures. Such reductions, or cost offsets, have been found following mental health treatment of distressed elderly medical inpatients, some patients as they develop major medical illnesses, primary care outpatients with multiple unexplained somatic complaints, and nonelderly adults with alcoholism. In this paper we argue that managed care has an opportunity to capture these medical care cost savings by training utilization managers to make mental health services more accessible to patients whose excessive use of medical care is related to psychological factors. For financial reasons, such policies are most likely to develop within health care plans that integrate the financing and management of mental health and medical/surgical benefits.     

Peer Reviewed: Making Room for Mental Health in the Medical Home

Discussions of health care reform emphasize the need for coordinated care, and evidence supports the effectiveness of medical home and integrated delivery system models. However, mental health often is left out of the discussion. Early intervention approaches for children and adolescents in primary care are important given the increased rates of detection of mental illness in youth. Most adults also receive treatment for mental illness from nonspecialists, underscoring the role for mental health in medical home models. Flexible models for coordinated care are needed for people with serious mental illness, who have high rates of comorbid medical problems. Programs implemented in the New York State public mental health system are examples of efforts to better coordinate medical and mental health services.     

Impact of prior and current alcohol use on use of services by patients with depression and chronic medical illnesses.

OBJECTIVE. Alcohol use often co-occurs with other major chronic conditions, but its effect on health care utilization in this context is not understood. This study examines the impact of alcohol consumption on health care use by patients with chronic medical conditions or depression, or both. DATA SOURCES/STUDY SETTING. Data came from the Medical Outcomes Study, an observational study of patients from the offices of general medical providers and mental health specialists in three U.S. cities. STUDY DESIGN. Longitudinal data spanning four years for outpatient general medical visits and outpatient mental health visits were analyzed using a two-part model to assess the impact of alcohol use disorder, problem drinking, and current and past alcohol consumption on health care use by patients, controlling for patient demographics and health status. DATA COLLECTION/EXTRACTION METHODS. Data were collected from 2,546 adult patients with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), and/or current major depression or subthreshold depression using periodic, self-report surveys detailing health care utilization and health status information. PRINCIPAL FINDINGS. Current alcohol consumption increases outpatient doctor visits, and problems related to current drinking decrease outpatient mental health visits. CONCLUSIONS. Patterns of alcohol consumption have an impact on both mental health and overall health care use by patients with chronic medical conditions or depression.     

Mental Health Service Use Types Among Asian Americans with a Psychiatric Disorder: Considerations of Culture and Need

Despite levels of need that are comparable with other groups, relatively few Asian Americans receive mental health care. While studies have described the tendency for Asian Americans to delay care until mental health symptoms are severe, relatively little research has examined how the severity of symptoms impact mental health service use. This study uses publicly available data from the National Latino and Asian American Study (NLAAS) and focuses solely on Asian American respondents with a psychiatric disorder (n?=?230). Unexpectedly, few Asian Americans with a psychiatric disorder received care in a medical setting. The perception of mental health needs increased the likelihood of using mental health specialist care. Social and systemic barriers together hinder mental health service use. Implications for addressing Asian American mental health service use within a changing health care environment are discussed.     

Ethnicity, gender, and utilization of mental health services in a Medicaid population

This study examines gender and ethnic differences in mental health utilization and expenditures in a fee-for-service Medicaid eligible population in Monroe County, New York. The analyses demonstrate that Medicaid poor are not a homogeneous population in terms of mental health utilization, and that their patterns of care use are quite unlike those generally attributed to the middle class patients. For example, Medicaid eligible males are more likely to be mental health users than females, although they are less likely to use medical services. Ethnicity appears to be a strong determinant of ambulatory mental health utilization, but not of inpatient care. Whites experience significantly higher levels of psychiatric ambulatory use than do the nonwhites. Nonwhites, on the other hand experience greater utilization of alcohol ambulatory services than do the whites. The data indicate that although mental health care cost represents at least 20% of total expenditures in this population, this cost is predictable and stable from year to year. Other analyses dealing with the cost of medical care for mental health users, and with the impact of a 'gate keeper' on mental health utilization patterns, are presented. Both clinical and public policy implications are discussed.     

Quality and customers: Type 2 change in mental health delivery within health care reform

The traditional separation of mental health and medical programs is problematic because mental health issues are inseparable from the larger medical system. By contrast, a collaborative primary care model of mental health care, augmented and supported by secondary specialty mental health services, has the potential to optimize quality and cost goals while reinforcing health care reform principles. The flexibility of mental health treatment in this delivery structure provides opportunities to customize services according to patient and purchaser expectations. with the Hay Group Inc.     

Depression hurts,depression costs: The medical spending attributable to depression and depressive symptoms in China

Due to its fast economic growth and lifestyle changes, China is experiencing a rapid epidemiological transition from communicable to noncommunicable diseases (NCDs). Mental disorder such as depression is an important yet often neglected NCD and is becoming a growing cause of disability, suicides, and disease burden. This paper provides the first nationally representative estimate of the medical cost attributable to depression and depressive symptoms among the adult population in China. On the basis of the 2012 China Family Panel Studies survey, our results indicate that these mental health conditions have significant impacts on the individual medical expenditure, and they jointly contribute to 14.7% of total personal expected medical spending in China, with depression and depressive symptoms accounting for 6.9% and 7.8%, respectively. Given that patients with mental illness face multiple psychological and institutional barriers in seeking appropriate treatment, the high depression‐induced medical costs may be primarily driven by the cost‐shifting effect from mental health care to general health care, as mental disorders often coexist with other NCDs such as diabetes and hypertension. As an implication, our study calls for an urgent reform of China's mental health and insurance systems to remove the policy‐induced obstacles for the access to mental health care resources.     

Posttraumatic Stress Disorder in Rural Primary Care: Improving Care for Mental Health Following Bioterrorism

CONTEXT: Recent bioterrorism attacks have highlighted the critical need for health care organizations to prepare for future threats. Yet, relatively little attention has been paid to the mental health needs of rural communities in the wake of such events. A critical aspect of bioterrorism is emphasis on generating fear and uncertainty, thereby contributing to increased needs for mental health care, particularly for posttraumatic stress disorder, which has been estimated to occur in 28% of terrorism survivors. PURPOSE: Prior experience with natural disasters suggests that first responders typically focus on immediate medical trauma or injury, leaving rural communities to struggle with the burden of unmet mental health needs both in the immediate aftermath and over the longer term. The purpose of the present article is to draw attention to the greater need to educate rural primary care providers who will be the frontline providers of mental health services following bioterrorism, given the limited availability of tertiary mental health care in rural communities. METHODS: We reviewed the literature related to bioterrorism events and mental health with an emphasis on rural communities. FINDINGS AND CONCLUSIONS: Public health agencies should work with rural primary care providers and mental health professionals to develop educational interventions focused on posttraumatic stress disorder and other mental disorders, as well as algorithms for assessment, referral, and treatment of post-event psychological disorders and somatic complaints to ensure the availability, continuity, and delivery of quality mental health care for rural residents following bioterrorism and other public health emergencies.     

Which Domain of Self-Rated Health Best Predicts Medical Care Utilization Among Taiwanese Adults?

Background: We attempted to identify the domain of self-rated health (SRH) that best predicts medical care utilization among Taiwanese adults. In addition, we examined the association between SRH and different measure of medical care utilization.Methods: We analyzed data on 11 987 community-dwelling adults aged 18 to 64 years from the 2005 Taiwan National Health Interview Survey (NHIS). NHIS data were linked to the 2006 National Health Insurance (NHI) administrative database. Then, medical care utilization in 2006, including all outpatient visits, hospitalizations, and mental health outpatient visits, was identified. Domain-specific health ratings were measured by using the Short Form-36 (SF-36) health survey questionnaire. Negative binominal models were used to estimate the contribution of the health domains to medical care utilization. Incidence rate ratios (IRRs) are presented.Results: The IRR for the physical component scale showed that those with the highest scores had 77% of the outpatient visits of those with the lowest scores. The importance of mental health domains was markedly higher in estimating mental health outpatient visits. Those with mental health scores above the median had only 61% of mental health outpatient visits of those with scores below the median.Conclusions: A person's medical care utilization is reflected in the different domains of general health. Domain-specific measures of subjective health are not interchangeable with global general health ratings, because different domains have independent effects on medical care utilization. Our results are potentially important for medical resource allocation because they identify different health domain experiences that require improvement.     

Health care use and at-work productivity among employees with mental disorders

This study examines the differential medical care use and work productivity of employees with and without anxiety and with other mental disorders at a large national firm. A unique aspect of this study is that we integrate medical claims and employer-provided, objective productivity data for the same employees. We find extensive mental health comorbidities among anxious employees. Although medical care use differs considerably among employees having no, one, or several treated mental disorders, in most cases their annual average absenteeism and average at-work productivity performance do not differ. Differences among subgroups are observed for job tenure and maternity claims. We discuss these long-term average productivity findings in relation to other literature encompassing shorter time periods.     

Preparing the workforce for integrated healthcare: A systematic review

Integrated healthcare is recommended to deliver care to individuals with co-occurring medical and mental health conditions. This literature review was conducted to identify the knowledge and skills required for behavioral health consultants in integrated settings. A review from 1999 to 2015 identified 68 articles. Eligible studies examined care to the U.S. adult population at the highest level of integration. The results provide evidence of specific knowledge of medical and mental health diagnoses, screening instruments, and intervention skills in integrated primary care, specialty medical, and specialty mental health. Further research is required to identify methods to develop knowledge/skills in the workforce.     

Mental health services for youths in foster care and disabled youths.

OBJECTIVES: This study assessed whether mental health services for youths differ with respect to medical assistance aid category. METHODS: Computerized claims for 15,507 youths with Medicaid insurance in a populous county of a mid-Atlantic state were used to establish population-based prevalence estimates of mental disorders and psychotherapeutic treatments during 1996. RESULTS: An analysis of service claims revealed that the prevalence of mental disorders among youths enrolled in foster care (57%) was twice that of youths receiving Supplemental Security Income (SSI; 26%) and nearly 15 times that of other youths receiving other types of aid (4%). Rates of mental health service use were pronounced among foster care youths aged 6 to 14 years. Attention deficit/hyperactivity disorder, depression, and developmental disorders were the most prevalent disorders. Stimulants, antidepressants, and anticonvulsants were the most prevalent medications. CONCLUSIONS: Youths enrolled in foster care and youths receiving SSI use far more mental health services than do youths in other aid categories. Additional research should evaluate the complexity and outcomes of mental health services for youths in foster care.     

Unmet needs for specialty, dental, mental, and allied health care among children with special health care needs: are there racial/ethnic disparities?

We examined racial/ethnic disparities in unmet specialty, dental, mental, and allied health care needs among children with special health care needs (CSHCN) using data on 38,866 children in the National Survey of CSHCN. Compared with White CSHCN, Black CSHCN had significantly greater unmet specialty (9.6% vs. 6.7%), dental (16% vs. 8.7%), and mental (27% vs. 17%) health care needs. Hispanic CSHCN had greater unmet dental care needs (15.8% vs. 8.7%). Black females had greater unmet mental health care needs than other groups (41% vs. 13-20%). Most disparities disappeared after multivariate adjustment. Significant risk factors for unmet health care needs included uninsurance, having no personal doctor/nurse, poverty, and condition stability and severity. Eliminating unmet specialty, dental, and mental health care needs for all CSHCN, and especially minority CSHCN, may require greater efforts to reduce poverty and increase insurance coverage among CSHCN, better mental health care assessment of Black female CSHCN, and ensuring all CSHCN have a medical home.     

Physical and Mental Health and Access to Care Among Nonmetropolitan Veterans Health Administration Patients Younger Than 65 Years

CONTEXT: The 4.5 million military veterans treated by the Veterans Health Administration (VA) are believed to experience poorer physical and mental health than nonveterans. Furthermore, nonmetropolitan residents have less access to medical services, whether or not they are veterans in VA care. A direct comparison of metropolitan and nonmetropolitan veterans and nonveterans on a national health survey has not been reported, so it is not known whether nonmetropolitan VA patients experience similar medical need or access as other nonmetropolitan residents. PURPOSE: We sought to compare the perceptions of health status and access to care among metropolitan and nonmetropolitan veterans in VA care, other veterans, and nonveterans in a large national sample surveyed under the same conditions. METHODS: Male respondents to the 2000 Behavioral Risk Factor Surveillance System health survey were divided into veterans or nonveterans, VA users or nonusers, metropolitan or nonmetropolitan residents, and 1 of 3 age groups (18-44, 45-64, and 65(+)). Responses to questions about current health status, health coverage, and access to care were submitted to chi-square analyses or analyses of variance, using SUDAAN software to compute survey error variance. FINDINGS: Nonmetropolitan VA patients younger than 65 years consistently reported the worst physical and mental health status and reduced access to care. CONCLUSIONS: VA can anticipate increasing demand for mental and physical health care among rural veterans younger than 65 years.     

The fracturing of medical dominance in British psychiatry?

Medical dominance is not a transhistorical and invariant property of the medical profession. Rather it is a set of occupational privileges that can be invoked or revoked according to changing alignments of political, economic and cultural power. Using the example of British psychiatry in the context of the health service reforms of the 1980s, it is argued that medical dominance may be fracturing as a result of the policy switch towards community mental health care and the managerial reorganisation of the health services. Knowledge claims and medical procedures that have legitimated the dominant position of psychiatry within the mental health services - a medico-eclectic ideology, a view of doctor superiority over other mental health professionals and the extensive use of physical treatments—are outlined and contrasted with the conflicting ideas and authority structures of community care and health service management. Challenges to medical dominance in mental health, it is contended, are represented by the legislative empowerment of a range of previously subordinated groups of professionals and para professionals. This paper draws primarily upon two sources of data; an ethnography and in-depth interview study of 40 psychiatrists and managers in the Bristol area in 1989–90 and an analysis of the writings of psychiatrists in the professional press.     

Mental health attitudes and practices of Soviet Jewish immigrants

This article describes some of the difficulties Soviet Jewish immigrants face and the results of a survey of immigrant attitudes toward western mental health resources. The author identifies doctors and medical facilities as primary mental health resources and explores implications for social work service delivery in ambulatory care settings. Comparisons with other populations also are made.