Psychiatric inpatient,outpatient, and medication utilization and costs among privately insured youths, 1997-2000

OBJECTIVE: The study examined trends in use of inpatient and outpatient mental health services, including pharmacotherapy, among privately insured children and adolescents from 1997 to 2000. METHOD: Data from a national database of more than 1.7 million privately insured individuals were used in an analysis of inpatient, outpatient, and pharmacy claims of users of mental health care age 17 years and younger (approximately 20,000 patients per year). Annual utilization rates and adjusted costs for services and dispensed psychotropic medications were calculated. Results from 1997 and 2000 were compared across diagnostic and age categories. RESULTS: The proportion of youths with an inpatient psychiatric admission decreased by 23.7% from 1997 to 2000, and annual inpatient and outpatient costs decreased by 1,216 US dollars (18.4%) and 157 US dollars (14.4%), respectively. Decreases were driven by a reduction in inpatient days (20.0%) and by a combination of a reduction in outpatient visits (11.3%) and declining payments per outpatient visit (6.1%). Payment trends across diagnoses varied considerably, with the largest reductions seen in treatment of depression, hyperactivity, adjustment disorders, and anxiety disorders. Over the same period, the proportion of youths receiving medication increased by 4.9%, and mean annual medication-related costs per outpatient increased by 41 US dollars (12.1%). CONCLUSIONS: Reductions in inpatient and outpatient mental health service intensity and reimbursements documented in previous research continued through the late 1990s. Declines were accompanied by concurrent increases in the use of and costs associated with psychotropic medications, particularly for youths with mood and anxiety disorders. These results document a shift toward medication-based outpatient treatment modalities.     

Current and Future Trends in Hospital Utilization of Patients With Schizophrenia in Korea: A Time Series Analysis Using National Health Insurance Data

Objective This study aimed to investigate trends in hospital utilization of patients with schizophrenia during the last 10 years in Korea and to predict future trends using time series analysis. Methods We determined the numbers of patients receiving outpatient or inpatient treatment for schizophrenia per month between 2010 and 2019, using National Health Insurance claims data. Facebook’s Prophet was used to fit time series models based on observations for the previous 120 months, and to predict trends over the next 36 months. Results The number of hospitalized patients per month has declined rapidly since 2015, but the monthly number of outpatient visits has steadily increased. Monthly hospital utilization has increased in patients aged ≤29 and ≥50 years, but has declined rapidly since 2014–2015 in patients in their 30s and 40s. The upward trend in overall hospital utilization has slowed considerably in recent years. These trends are expected to continue over the next few years. Conclusion This study revealed some notable changes in the hospital utilization patterns of patients with schizophrenia in recent years. There is a need to closely monitor and anticipate potential problems caused by these changing trends.     

Psychiatric inpatient care in the VA: before, during, and after DRG-based budgeting

OBJECTIVE: The authors examined the impact of budgeting based on diagnosis-related groups (DRGs) on inpatient psychiatric care in Department of Veterans Affairs (VA) medical centers. DRG-based budgeting was implemented by the VA in 1984 and suspended in 1988. METHOD: Computerized discharge abstracts were obtained for all episodes of VA inpatient care occurring from 1980 through 1989. The number of discharges per year, number of unduplicated patients treated, mean length of stay, total number of bed days of care per unique patient per year, readmission rates, and number of episodes of care per operational bed were determined for psychiatric and nonpsychiatric (medical-surgical) hospitalizations occurring before, during, and after DRG-based budgeting was in effect. RESULTS: In the case of VA psychiatric care, DRG-based budgeting was associated with more episodes of care, shorter lengths of stay, higher readmission rates, and more episodes of care per occupied bed. DRG-based budgeting had similar effects on medical-surgical care, although an increase in the number of episodes of care was not observed. During the first year after this funding mechanism was suspended, changes in both psychiatric and medical-surgical care that were related to DRG-based budgeting were slowed and, in some cases, reversed. CONCLUSIONS: Both psychiatric and medical-surgical inpatient care in the VA were sensitive to changes in funding mechanisms. These changes were generally similar to those observed in psychiatric care provided by non-VA hospitals reimbursed under Medicare's DRG-based prospective payment system.     

Bed closures and incarceration rates among users of Veterans Affairs mental health services

OBJECTIVE: This study examined incarceration rates of users of Department of Veterans Affairs (VA) mental health services in 16 northeastern New York State counties between 1994 and 1997-a time of extensive bed closures in the VA system-to determine whether incarceration rates changed during this period. METHODS: Data were obtained for male patients who used inpatient and outpatient VA mental health services between 1994 and 1997 and for men incarcerated in local jails during this period. For comparison, services use and incarceration data were obtained for all men who received inpatient behavioral health care at community general hospitals and state mental hospitals between 1994 and 1996 in the same counties. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between clinical and incarceration populations without relying on person-specific identifiers. RESULTS: Of all male users of VA mental health services between 1994 and 1997, a total of 15.7 percent-39.6 percent of those age 18 to 39 years and 9.1 percent of those age 40 years and older-were incarcerated at some time during that period. Dual diagnosis patients had the highest rate of incarceration (25 percent), followed by patients with substance abuse problems only (21 percent) and those with mental health problems only (11 percent). The rate of incarceration among male patients hospitalized in VA facilities was lower than among men in general hospitals or state hospitals (11.6 percent, 23 percent, and 21.7 percent, respectively), but was not significantly different. No significant increase occurred in the annual rate of incarceration among VA patients from 1994 to 1997 (3.7 percent to 4 percent), despite extensive VA bed closures during these years. CONCLUSIONS: Substantial proportions of mental health system users were incarcerated during the study period, especially younger men and those with both substance use and mental health disorders. Rates of incarceration were similar across health care systems. The closure of a substantial number of VA mental health inpatient beds did not seem to affect the rate of incarceration among VA service users.     

Establishing a function-based mental health service line in a VA medical center

From 1994 through 1996, a general Veterans Affairs (VA) medical center reorganized its mental health services from a traditional discipline-based structure to a unitary service line organized around patient care functions. A comparison of data from 1993 and 1997 indicated increased efficiency, substantial transfer of patients from inpatient to outpatient care, and growth in academic programs not explainable solely by temporal, regional, or national trends or by trends within the VA medical center. Although the results should be interpreted conservatively because of the observational nature of the study, the reorganization appeared to facilitate the positive changes that occurred over the study period.     

Shifting to outpatient care? Mental health care use and cost under private insurance.

OBJECTIVE: Concern over rising health care costs has put pressure on providers to reduce costs, purportedly by reducing inpatient care and increasing outpatient care. METHOD: Inpatient and outpatient claims were analyzed for adult users of mental health services (180,000/year on average) from a national study group of 3.9 million privately insured individuals per year from 1993 to 1995. Costs and treatment days per patient were compared across diagnostic groups and stratified by whether patients were hospitalized. RESULTS: Inpatient mental health costs fell $2,507 (30.4%) over the period, driven primarily by decreases in hospital days per patient per year (19.9%), with smaller changes in the proportion of enrollees who received inpatient care (increase of 0.8%) and a decrease in per diem costs (9.1%). Outpatient mental health costs also declined over the period, falling 13.6% for patients also using inpatient services and 14.6% for patients receiving only outpatient care. Patients whose primary diagnosis was mild to moderate depression saw the largest decreases in inpatient cost per patient (42.8%); those diagnosed with schizophrenia experienced the smallest decrease (23.5%). For patients using outpatient services only, those diagnosed with substance abuse experienced the largest decrease in costs (23.5%); those diagnosed with schizophrenia experienced the smallest decrease (8.6%). CONCLUSIONS: Substantial cost reductions for mental health services are primarily a result of reductions in inpatient and outpatient treatment days. Declines in inpatient service use were not accompanied by increases in outpatient service use, even for severely ill patients requiring hospitalization. Managed care has not caused a shift in the pattern of care but an overall reduction of care.     

Treatable comorbid conditions and use of VA health care services among patients with dementia

OBJECTIVE: Although dementia is a progressive degenerative disease, treatable comorbid symptoms, such as pain, aggression, depression, and psychosis, occur among more than 60 percent of patients with dementia. Compared with age-matched controls, patients with dementia use 70 percent more health services and account for 50 percent more managed care costs. This prospective study examined the longitudinal relationship between use of health care services and treatable comorbid conditions among patients with dementia. METHODS: Ninety-nine patient-caregiver dyads from the Michael E. DeBakey Veterans Affairs (VA) Medical Center in Houston, Texas, completed a one-time interview. Patients' VA records were reviewed one year later to examine the relationships between the study variables and three types of service use: inpatient medical stays, outpatient medical visits, and outpatient psychiatric visits. RESULTS: Pain was positively associated with all types of service use. Depression was associated with outpatient psychiatric visits. Psychosis and aggression were not significantly associated with future use of health care services. CONCLUSIONS: The results of this study confirm previous findings that pain and depression are associated with increased use of health care services. Although the other treatable comorbid symptoms, with the exception of pain, are associated with increased service use, their impact varies depending on the type of services provided. Interventions to improve the assessment and treatment of comorbid symptoms, especially pain, among patients with dementia may reduce service needs and thus reduce medical care costs.     

Patterns of health care costs associated with depression and substance abuse in a national sample

OBJECTIVE: The associations between self-reported depressive and substance use disorders and estimated health care costs were examined in a representative national sample. METHODS: Data were from the 1994 National Health Interview Survey (N=77,183). Respondents who reported depressive symptoms or major depression (depressive syndromes) or a substance abuse disorder in the past year were compared with respondents who did not report these conditions. The mean number of inpatient days and outpatient visits in both the general medical and the specialty mental health settings were determined, and costs per individual were calculated based on mean costs of such care in each respondent's geographic region. Multivariate models were constructed to calculate mean costs, controlling for demographic variables, insurance coverage, and physical health status. RESULTS: Individuals with self-reported depressive syndromes or substance abuse had mean health care costs that were $1,766 higher than costs for individuals without these conditions. Depressive syndromes were associated with increases in both inpatient and outpatient costs. However, substance abuse was almost exclusively associated with increased inpatient expenditures rather than outpatient costs. The magnitude of increased costs associated with mental disorders was substantially larger for patients in fee-for-service plans than for those in health maintenance organizations. Only 14.3 percent of visits made by individuals reporting depressive syndromes or substance abuse were made to specialty health providers (psychiatrists, psychologists, and social workers). CONCLUSIONS: Health care costs of people with self-reported mental illness varied significantly across diagnoses and systems of care. It is crucial that researchers estimating increased costs associated with mental illness account for both diagnostic and system factors that can influence the estimates.     

Access to and patterns of use of behavioral health services among children and adolescents in TennCare

OBJECTIVE: This study assessed trends in access to and use of behavioral health services for school-aged children in TennCare, Tennessee's Medicaid managed care program, between state fiscal years 1995 and 2000. METHODS: Claims, encounter, and enrollment data from the Bureau of TennCare were used. The data analyzed were restricted to services and enrollment periods for children and adolescents between the ages of four and 17 years at the time of service or enrollment. Measures were calculated in four areas: overall access to behavioral health services, use of inpatient services, use of outpatient specialty treatment services, and use of supportive services like case management and medication management. RESULTS: The number of youths who received a behavioral service increased by nearly 50 percent between state fiscal years 1995 and 2000. At the same time, the number of youths enrolled in TennCare increased by 19 percent. The annual access rate increased from 72.7 youths per 1000 enrollees to 91.7. However, the volume of services for children fell. Access rates were low relative to estimates of need in this population. The system made less use of inpatient services and relied more on outpatient services, particularly case management and medication management services. CONCLUSIONS: Children's access rates for behavioral health services improved even as the TennCare program expanded to cover more children. The system served more youths in part by reducing the volume of services for children receiving treatment and substituting more supportive services. Ongoing performance monitoring for policy making will require enhancements of data monitoring activities by the state.     

Comparing quality of mental health care for public-sector and privately insured populations

OBJECTIVE: This study examined the methodological difficulties of comparing quality of care in large health care systems. It demonstrated methods for measuring quality of mental health care and, using these measures, compared patients from Department of Veterans Affairs (VA) hospitals with privately insured patients. METHODS: Individuals receiving VA inpatient mental health care during the first six months of each fiscal year from 1993 to 1997 were identified from discharge abstracts. A similar cohort of privately insured individuals was identified using MEDSTAT's MarketScan database from 1993 to 1995. Individuals in both cohorts were tracked for six months after discharge. Length of stay, readmission rates, and access to outpatient services were calculated. RESULTS: The private sector outperformed VA on most quality measures, although differences were modest and can likely be explained by the greater severity of illness and social disadvantages of VA patients. Readmission rates increased considerably over time in the private sector, whereas they declined for VA patients. Quality measures varied by diagnosis, with VA performing better than the private sector in treating patients diagnosed with substance abuse and mental disorders not elsewhere classified but worse in treating patients diagnosed with depression. CONCLUSIONS: Although the private sector modestly outperformed VA on most quality measures, VA treats a more troubled population, and it improved markedly over time compared with the private sector. As health systems strive to reduce costs of care, methods for comparing and evaluating the quality of care become increasingly important. However, methodological challenges remain substantial.     

Do we still need beds for psychiatric patients?

While the utilization of outpatient psychiatric care increased steeply in the last few decades, the number of beds in psychiatric hospitals declined continuously in most countries. The future need for psychiatric hospital beds is influenced by changes in psychiatric morbidity, the range of services offered by mental hospitals and the availability of alternative forms of care for the chronically ill. A prospective cohort study conducted in Mannheim showed that currently, at a favourable standard of complementary service provision, one quarter of the schizophrenic patients requiring institutional care for more than one year - schizophrenics are the largest group of mental patients in need of long-term residential care - still need to be treated in mental hospitals. Beyond this threshold value the costs of alternative care exceed those of a continuous inpatient treatment, and, concurrently with them, the burden upon the people involved grows. Estimates of the future need can be made on the basis of field surveys, utilization data of a population and an analysis of long-term trends by using case register data. Provided a well-functioning system of alternative and outpatient mental health services is available, psychiatric bed ratios covering the actual needs in developed countries seem to range from 0.5 to 0.8 per 1000 population over 15 for the short-stay group and from 0.3 to 0.6 per 1000 for long-stay patients. The uncertainty inherent in the estimates requires a sufficient degree of flexibility in service planning and a continuous monitoring to make adjustments to changed conditions possible.     

Expenditures on mental health and addictions for Canadian provinces in 2003 and 2004

OBJECTIVE: To measure total public and private expenditures on mental health in each province. METHOD: Data for expenditures on mental health services were collected in the following categories: physician expenditures (general and psychiatrist fees for service and alternative funding), inpatient hospital (psychiatric and general), outpatient hospital, community mental health, pharmaceuticals, and substance abuse. Data for 2 years, 2003 and 2004, were collected from the Canadian Institute for Health Information (hospital inpatient and fees for service physicians), the individual provinces (pharmaceuticals, alternative physician payments, hospital outpatient, and community), and the Canadian Centre on Substance Abuse. Totals were expressed in terms of per capita and as a percentage of total provincial health spending. RESULTS: Total spending on mental health was $6.6 billion, of which $5.5 billion was from public sources. Nationally, the largest portion of expenditures was for hospitals, followed by community mental health expenses and pharmaceuticals. This varied by province. Public mental health spending was 6% of total public spending on health, while total mental health spending was 5% of total health spending. CONCLUSIONS: Canadian public mental health spending is lower than most developed countries, and a little below the minimum acceptable amount (5%) stated by the European Mental Health Economics Network.     

Mental health staff and patient's relatives: how they view each other

As part of a project to better serve the needs of patients' families, a New York state psychiatric facility surveyed 350 inpatient and outpatient staff and 250 family members about their attitudes toward each other and about the role of families in the patients' treatment. Generally staff felt positively about families and believed they should be meaningfully involved in the patients' treatment, but 61 percent reported spending less than one hour per week in contact with families. Staff cited conflict among themselves about the role of families and lack of time as the greatest impediments to interacting with families. Most families felt staff were supportive of them, but only 19 percent said staff provided them with enough information. Less than 21 percent had been invited to treatment planning meetings or to discharge conferences. The center is currently implementing training programs and administrative changes intended to increase cooperation between staff and patients' families.     

Changes in insurance coverage and extent of care during the two years after first hospitalization for a psychotic disorder

OBJECTIVE: This study examined changes in insurance coverage during the 24 months after first admission for a psychotic disorder and the relationship of insurance type to the extent of care. METHODS: The sample consisted of 443 persons who were enrolled in the Suffolk County (New York) Mental Health Project. Information about coverage-private insurance, Medicaid-Medicare, or no insurance-was obtained from hospital records and interviews. The insurance status groups were compared to examine differences in the percentage of days they received inpatient, outpatient, and day hospital care. Results and CONCLUSIONS: The proportion of persons with no insurance decreased from baseline to 24 months, from 42 percent to 21 percent. The proportion of persons with private insurance remained similar, 42 and 37 percent. The proportion of those with Medicaid-Medicare increased from 15 percent to 42 percent. Of those with Medicaid-Medicare at baseline (67 persons), 88 percent had such coverage 24 months later. Of those with private insurance at baseline (188 persons), 73 percent had the same coverage 24 months later. Of those with no insurance at baseline (188 persons), 35 percent had no insurance at 24 months, 54 percent had Medicaid-Medicare, and 11 percent had private insurance. Over the 24 months, the Medicaid-Medicare group had the most days of care, the private insurance group had the least inpatient care, and those with no insurance were least likely to receive outpatient care. There was a linear relationship between receiving more outpatient care and spending less time in the hospital and the day hospital.     

Treatment, care, and rehabilitation of the chronic mentally ill in Poland

In Poland primary health settings provide about 71 percent of mental health services, particularly to patients with less serious illnesses, while psychiatry provides specialized mental health care for the chronic mentally ill, the mentally retarded, and patients with alcohol or drug dependence. Poland has a large number of outpatient clinics and an extensive network of sheltered workshops. Most inpatient psychiatric beds are located in mental hospitals; few general hospitals have psychiatric units. Deinstitutionalization has been less extensive in Poland than in many other countries; only about 10 percent of the chronic patients treated in mental hospitals were deinstitutionalized between 1970 and 1981. During that period the proportion of patients hospitalized for a year or more decreased, the number of chronic patients treated in nursing homes increased, and the pattern of hospitalization shifted toward multiple readmissions.     

Trends in discharge disposition,mortality, and service use among long-stay psychiatric patients in the 1990s

OBJECTIVE: This study examined changes in discharge disposition, mortality, and service use among three cohorts of highly vulnerable long-stay psychiatric patients in the Department of Veterans Affairs (VA) mental health system during the 1990s, a period of extensive bed closures. METHODS: National VA administrative databases were used to identify and prospectively follow three long-stay cohorts: mental health inpatients who had been hospitalized for at least one year as of the end of fiscal year 1991 (N=2,343), 1994 (N=1,853), and 1997 (N=1,156). The cohorts were compared in baseline demographic and diagnostic characteristics as well as discharge disposition, mortality, and service use over a three-year follow-up period. RESULTS: Nationally, the number of occupied long-stay beds decreased by 50 percent between 1991 and 1997. Over time, significant changes were noted in long-stay patients' principal diagnoses and discharge dispositions. Compared with the 1991 cohort, the 1994 and 1997 cohorts had a higher proportion of patients with psychotic disorders (69 percent, 77 percent, and 75 percent, respectively) and were more likely to be discharged from the hospital during the three-year follow-up period (33 percent, 54 percent, and 53 percent, respectively). However, among patients who were discharged, no substantial differences were noted in either mortality or overall VA service use across the three cohorts. CONCLUSIONS: The delivery of inpatient VA mental health services changed dramatically during the 1990s. This study provided evidence that continuing efforts to close VA mental health beds have not resulted in substantially adverse changes in mortality rates or in the extent to which long-term inpatients remain connected with the VA system after discharge.     

A survey of assaultive behavior in Veterans Health Administration facilities

OBJECTIVE: To more clearly define the scope and impact of violence in health care facilities, national data on assaults in VA medical centers and freestanding clinics were examined. METHODS: A survey was distributed to all VA medical centers and freestanding clinics asking for cumulative data for one fiscal year (October 1990 through September 1991). Data were obtained on number, types, and locations of physical assaults and other assaultive behavior; the types of staff assaulted and number of workdays lost due to injuries; diagnoses of perpetrators; recommendations made after the incidents were reviewed; training in prevention and management of assaultive behavior; and the impact of training on rates of assaultive behavior. RESULTS: During the survey year, 24,219 incidents of assaultive behavior were reported by 166 VA facilities; 8,552 incidents involved battery or physical assault. Weapon possession by perpetrators was common (8.5 percent of incidents), and weapons were used in 130 assaults (1.5 percent of assaults). Assaults occurred most frequently in psychiatric units (43.1 percent), followed by long-term-care units (18.5 percent) and admitting or triage areas (13.4 percent). Assault-related injuries were most common among nursing personnel. Perpetrators of assaults were most typically diagnosed as having psychoses, substance use disorders, or dementia. On inpatient psychiatry units, an inverse correlation was found between expenditures on staffing and the frequency of assaultive incidents. Staff training on management of assaultive behavior varied widely. CONCLUSIONS: Assaultive behavior is a significant problem for health care workers. Staff in all clinical areas need to be prepared to deal with assaultive patients. More research is needed on staff training and interventions for preventing and limiting assaults.     

Trends in the inpatient mental health treatment of children and adolescents in US community hospitals between 1990 and 2000

CONTEXT: Previous work has demonstrated marked changes in inpatient mental health service use by children and adolescents in the 1980s and early 1990s, but more recent, comprehensive, nationally representative data have not been reported. OBJECTIVE: To describe trends in inpatient treatment of children and adolescents with mental disorders between 1990 and 2000. DESIGN AND SETTING: Analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, a nationally representative sample of discharges from US community hospitals sponsored by the Agency for Healthcare Research and Quality. PATIENTS: Patients aged 17 years and younger discharged from US community hospitals with a principal diagnosis of a mental disorder. MAIN OUTCOME MEASURES: Changes in the number and population-based rate of discharges, total inpatient days and average length of stay, charges, diagnoses, dispositions, and patient demographic and hospital characteristics. RESULTS: Although the total number of discharges, population-based discharge rate, and daily charges did not significantly change between 1990 and 2000, the total number of inpatient days and mean charges per visit each fell by approximately one half. Median length of stay declined 63% over the decade from 12.2 days to 4.5 days. Declines in median and mean lengths of stay were observed for most diagnostic categories and remained significant after controlling for changes in background patient and hospital characteristics. Discharge rates for psychotic and mood disorders as well as intentional self-injuries increased while rates for adjustment disorders fell. Discharges to short-term, nursing, and other inpatient facilities declined. CONCLUSIONS: The period between 1990 and 2000 was characterized by a transformation in the length of inpatient mental health treatment for young people. Community hospitals evaluated, treated, and discharged mentally ill children and adolescents far more quickly than 10 years earlier despite higher apparent rates of serious illness and self-harm and fewer transfers to intermediate and inpatient care.