Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO

OBJECTIVE: Little is known about how psychiatric disorders affect health care costs in Medicaid programs. The prevalence of psychiatric disorders and costs of care for members of a Medicaid health maintenance organization (HMO) who had psychiatric disorders were examined. METHODS: A cross-sectional, observational analysis of adult Medicaid beneficiaries over a 12-month period was conducted by using data from a health plan that has both an HMO and a behavioral health carve-out. Claims data were analyzed for 6,500 adults who were eligible for services in both plans and who received medical or behavioral health services during calendar year 2000. RESULTS: Thirty-nine percent of the 6,500 adults had a psychiatric diagnosis. Of this subset, 67.2 percent had received no specialty mental health care in the previous year. The presence of any psychiatric diagnosis significantly increased total health care costs by a factor of 2.24 ($6,995 compared with $3,121 for persons with no psychiatric diagnosis) and costs to the medical plan by a factor of 1.77 ($4,690 compared with $2,649). For beneficiaries with bipolar or psychotic diagnoses, higher health plan costs were due predominately to increases in pharmacy and specialty mental health costs. In contrast, higher costs for beneficiaries with depression, anxiety, or substance use diagnoses were attributable to greater use of general medical services. CONCLUSIONS: An analysis of claims data showed that adult Medicaid beneficiaries have exceptionally high rates of comorbid psychiatric conditions, which were associated with significantly higher medical and pharmaceutical costs. The high cost of these beneficiaries to the medical plan has policy implications in terms of the importance of addressing mental health issues in Medicaid general medical populations.     

An Economic Comparison of Risperidone and Olanzapine Use within an Integrated Managed Mental Health Program

This study assessed differences in total mental health care costs for 1 year following initiation of risperidone or olanzapine in individuals within NorthSTAR, an integrated managed mental health pilot project. A retrospective database analysis of individuals with schizophrenia or schizoaffective disorder and newly started on either agent was conducted. Antipsychotic medication costs were significantly lower for individuals prescribed risperidone than olanzapine ($1763 versus $2582; p<0.001). Individuals prescribed risperidone had lower (but not significant) expenditures for mental health services ($4714 versus $5077; p=0.792), as well as total mental health care costs ($7407 versus $9011; p=0.255).     

Clubhouse costs and implications for policy analysis in the context of system transformation initiatives

Objective: Documenting service costs is important for psychiatric rehabilitation programs to make persuasive arguments to policymakers/funders about their role in system transformation efforts. The purpose of this study was to report program costs, annual costs per member, and costs per day over three years (2003-2006) for 29 clubhouses that are part of the Pennsylvania Clubhouse Coalition (PCC). Methods: This study utilized data elements that are submitted annually by coalition members to the Pennsylvania Clubhouse Coalition. Results: Our results indicate that clubhouses play a substantial role in the Pennsylvania mental health system, providing almost 180,000 units of contact to more than 2,400 people across the state. Conclusions: Most relevant to Pennsylvania's system transformation is our finding that clubhouse costs are substantially lower than the costs of partial hospital services. Clubhouses are likely serving an important role in lowering costs associated with supporting those who would otherwise utilize partial hospital programs.     

Mental Health Consultation Among Ontario’s Immigrant Populations

To determine the prevalence rates and characteristics of past-year mental health consultation for Ontario’s adult (18?+?years old) immigrant populations. The Canadian Community Health Survey (CCHS) 2012 was used to calculate the prevalence rates of past-year mental health consultation by service provider type. Characteristics associated with mental health consultation were determined by carrying out multivariable logistic regression analysis on merged CCHS 2008–2012 data. Adult immigrant populations in Ontario (n?=?3995) had lower estimated prevalence rates of past-year mental health consultation across all service provider types compared to Canadian-born populations (n?=?14,644). Amongst those who reported past-year mental health consultation, 57.89% of Ontario immigrants contacted their primary care physician, which was significantly higher than the proportion who consulted their family doctor from Canadian-born populations (45.31%). The factors of gender, age, racial/ethnic background, education level, working status, food insecurity status, self-perceived health status, smoking status, alcohol drinking status, years since immigration, and age at time of immigration were significantly associated with past-year mental health consultation for immigrant populations. Ontario’s adult immigrant populations most commonly consult their family doctor for mental health care. Potential exists for expanding the mental health care role of primary care physicians as well as efforts to increase accessibility of specialized mental health services. Integrated, coordinated care where primary care physicians, specialized mental health professionals, social workers, and community educators, etc. working together in a sort of “one-stop-shop” may be the most effective way to mitigate gaps in the mental health care system. In order to effectively tailor mental health policy, programming, and promotion to suit the needs of immigrant populations initiatives that focus on the connection between physical and mental health and migration variables such as length of stay in Canada, years since immigration, and other important migration variables (beyond the scope of the CCHS which require further study) need to be developed. Examination of the social determinants of mental health is critical to understand how we can best serve the mental health needs of Ontario’s immigrant populations.     

Factors associated with interest in receiving help for mental health problems in combat veterans returning from deployment to Iraq

Mental health problems in service members often go untreated. This study focused on factors related to interest in receiving help in a survey sample of 577 combat veterans who were screened positive for posttraumatic stress disorder, depression, or generalized anxiety disorder 3 months after returning from Iraq. Over three quarters of respondents recognized that they had a current problem, but only 40% were interested in receiving help. Interest in receiving help was associated with recognizing a problem and receiving mental health services in the past year. More negative attitudes toward mental health care were associated with lower interest in receiving help; paradoxically, more negative perceptions of unit stigma were associated with increased interest in receiving help. Further studies are needed to better define the relationship between stigma perceptions, interest in receiving care, and actual care utilization and to determine whether attitudes toward mental health care can be modified through changes in how care is delivered. Attitudes toward mental health care should be considered in treatment interventions.     

The cost of access to mental health services in managed care

Managed care has controlled the cost of specialty mental health services, but its impact on access to care is not well described. In a retrospective design, the study used empirical data to demonstrate a direct relationship between managed care plans' claims costs per member per month and the proportion of plan members who use specialty mental health services annually. Each increment of $1 per member per month in spending on claims was associated with a.9 percent increase in the proportion of enrollees receiving specialty mental health treatment. These data raise concerns that plans with low per-member per-month costs may unduly restrict access to specialty treatment.     

Costs of health care use by women HMO members with a history of childhood abuse and neglect.

BACKGROUND: Early childhood maltreatment has been associated with adverse adult health outcomes, but little is known about the magnitude of adult health care use and costs that accompany maltreatment. We examined differences in annual health care use and costs in women with and without histories of childhood sexual, emotional, or physical abuse or neglect. METHODS: A random sample of 1225 women members of a health maintenance organization completed a 22-page questionnaire inquiring into childhood maltreatment experiences as measured by the Childhood Trauma Questionnaire. Health care costs and use data were obtained from the automated cost-accounting system of the health maintenance organization, including total costs, outpatient and primary care costs, and emergency department visits. RESULTS: Women who reported any abuse or neglect had median annual health care costs that were $97 (95% confidence interval, $0.47-$188.26) greater than women who did not report maltreatment. Women who reported sexual abuse had median annual health care costs that were $245 (95% confidence interval, $132.32-$381.93) greater than costs among women who did not report abuse. Women with sexual abuse histories had significantly higher primary care and outpatient costs and more frequent emergency department visits than women without these histories. CONCLUSION: Although the absolute cost differences per year per woman were relatively modest, the large number of women in the population with these experiences suggests that the total costs to society are substantial.     

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.     

The impact of managed care on cross-system use of mental health services by veterans in Colorado

OBJECTIVES: Some state mental health systems have implemented capitated managed care as a strategy for lowering mental health care costs. There has been concern that this strategy has left vulnerable populations at risk of not being able to obtain adequate care. This study examined whether the advent of managed care in Colorado resulted in lower rates of use of both state and Department of Veterans Affairs (VA) mental health care services (cross-system use). METHODS: A cohort of 10,950 veterans who had used VA mental health services between 1995 and 1997 were studied to determine whether veterans who lived in counties that had implemented managed care were less likely to be cross-system users over time. VA data were matched with state mental health data to determine who was using both types of services. RESULTS: Rates of cross-system use were generally low. Veterans who lived in a county that had implemented managed care were less likely to be cross-system users than veterans who lived in other counties. However, the proportions of cross system users in managed care counties and in other counties did not change significantly over time. Veterans who were cross-system users were more likely to be younger, to live farther away from a VA hospital and closer to a non-VA hospital, and to have received inpatient VA care. CONCLUSIONS: The implementation of managed care in Colorado did not appear to have affected rates of cross-system use of state and VA mental health care.     

Direct and indirect costs associated with epileptic partial onset seizures among the privately insured in the United States

Purpose: Compare annual direct and indirect costs between privately insured U.S. patients with epileptic partial onset seizures (POS) and matched controls. Methods: One thousand eight hundred fifty‐nine patients (including a subset of 758 employees) with ≥1 (POS) diagnosis (ICD‐9‐CM: 345.4.x–345.7.x), 1999–2004, ages 16–64 years, were identified from a privately insured claims database. Control group was an age‐ and gender‐matched cohort of randomly chosen beneficiaries without epilepsy (ICD‐9‐CM: 345.x). All were required to have continuous health coverage during 2004 (baseline) and 2005 (study period). Chi‐square tests were used to compare baseline comorbidities. Univariate and multivariate analyses were used for comparisons of annual direct (medical and pharmaceutical) and indirect costs during the study period. Results: Patients with POS were on average 42 years of age, and 57% were women. Patients with POS had significantly higher rates of mental health disorders, migraine, and other neurologic disorders, and higher Charlson comorbidity index (CCI) compared with controls. On average, direct annual costs were significantly higher for POS patients ($11,276) compared with controls ($4,087), p < 0.001; difference of $7,190. Epilepsy‐related costs (i.e., costs for antiepileptic drugs, claims with epilepsy or convulsions diagnoses) accounted for $3,290 (29% of direct costs). Employees with POS had substantial and significantly higher indirect (disability‐ and medically related absenteeism) costs compared with controls ($3,431 vs. $1,511, p < 0.001). Multivariate analyses supported the matched‐control univariate findings. Conclusion: Patients with POS had significantly higher costs compared with matched controls. Epilepsy‐related costs underestimate the excess costs of patients with partial onset seizures.     

Cost-Effectiveness of Individual Placement and Support Compared to Transitional Work Program for Veterans with Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) leads to significant disability, unemployment, and substantial healthcare costs. The cost-effectiveness of vocational rehabilitation (VR) interventions is important to consider when determining which services to offer. This study assesses the cost-effectiveness and return on investment of Individual Placement and Support (IPS) compared to transitional work (TW) programs. Employment outcomes from a multisite randomized trial comparing IPS to TW in military veterans with PTSD (n?=?541) were linked to Veterans Health Administration (VHA) archival medical record databases to examine the comparative cost-effectiveness and return on investment. Effectiveness was defined as hours worked and income earned in competitive jobs. Costs for VR, mental health, and medical care and income earned from competitive sources were annualized and adjusted to 2019 US dollars. The annualized mean cost per person of outpatient (including vocational services) were $3970 higher for IPS compared to TW ($23,245 vs. $19,276, respectively; P?=?0.004). When TW income was included in costs, mean grand total costs per person per year were similar between groups ($29,828 IPS vs. $26,772 TW; P?=?0.17). The incremental cost-effectiveness analysis showed that while IPS is more costly, it is also more effective. The return on investment (excluding TW income) was 32.9% for IPS ($9762 mean income/$29,691 mean total costs) and 29.6% for TW ($7326 mean income/$24,781 mean total costs). IPS significantly improves employment outcomes for individuals with PTSD with negligible increase in healthcare costs and yields very good return on investment compared to non-IPS VR services.

     

Direct Health Care Costs for Children with Pervasive Developmental Disorders: 1996–2002

We compared direct costs of treatment of Pervasive Developmental Disorder (PDD), asthma, and diabetes in children aged 3–17 years. A retrospective, claims-based study was conducted using the California Medicaid (Medi-Cal) database (1996–2002). Seven hundred and thirty-one children with PDD were identified and matched for sex with an equal number of randomly selected children with asthma and diabetes. Mean total health care costs for PDD were two- to threefold higher than for asthma and diabetes post-diagnosis ($4,815 vs. $1,469 vs. $2,404, respectively, P < 0.0001). Children with PDD incur significantly greater health care costs when compared with children with other chronic pediatric diseases.     

Somatic symptoms in adolescence as a predictor of severe mental illness in adulthood: a long-term community-based follow-up study

Background

Somatic symptoms are common and costly for society and correlate with suffering and low functioning. Nevertheless, little is known about the long-term implications of somatic symptoms. The objective of this study was to assess if somatic symptoms in adolescents with depression and in their matched controls predict severe mental illness in adulthood by investigating the use of hospital-based care consequent to different mental disorders.

Methods

The entire school population of 16–17-year-olds in the city of Uppsala, Sweden, was screened for depression in 1991–1993 (n?=?2300). Adolescents with positive screenings (n?=?307) and matched non-depressed controls (n?=?302) participated in a semi-structured diagnostic interview for mental disorders. In addition, 21 different self-rated somatic symptoms were assessed. The adolescents with depression and the matched non-depressed controls were engaged in follow-up through the National Patient Register 17–19 years after the baseline study (n?=?375). The outcome measures covered hospital-based mental health care for different mental disorders according to ICD-10 criteria between the participants’ ages of 18 and 35 years.

Results

Somatic symptoms were associated with an increased risk of later hospital-based mental health care in general in a dose–response relationship when adjusting for sex, adolescent depression, and adolescent anxiety (1 symptom: OR?=?1.63, CI 0.55–4.85; 2–4 symptoms: OR?=?2.77, 95% CI 1.04–7.39;?≥?5 symptoms: OR?=?5.75, 95% CI 1.98–16.72). With regards to specific diagnoses, somatic symptoms predicted hospital-based care for mood disorders when adjusting for sex, adolescent depression, and adolescent anxiety (p?<?0.05). In adolescents with depression, somatic symptoms predicted later hospital-based mental health care in a dose–response relationship (p?<?0.01). In adolescents without depression, reporting at least one somatic symptom predicted later hospital-based mental health care (p?<?0.05).

Conclusions

Somatic symptoms in adolescence predicted severe adult mental illness as measured by hospital-based care also when controlled for important confounders. The results suggest that adolescents with somatic symptoms need early treatment and extended follow-up to treat these specific symptoms, regardless of co-occurring depression and anxiety.

     

Mentally ill mothers and their children. An epidemiological study of antenatal care consumption, obstetric conditions, and neonatal health

Antenatal care consumption, obstetric conditions, and neonatal health, were studied retrospectively in all women in the county of Stockholm who had a baby during 1976-77 and also had been admitted to a psychiatric department after the 20th week of pregnancy or within the first postpartum year, and the findings were compared in matched obstetric controls. Fewer index women had had uncomplicated pregnancies than the controls. A positive relationship was found between acute mental illness and pregnancy complications. Delivery complications tended to to be more common in the index group than in controls, but, only in patients with prepartum onset of mental illness. More index women had a history of several previous abortions than the controls. The index women, and especially the addicts, attended the antenatal care clinics significantly less frequently than the controls. The neonatal health of the index children seemed to be more closely correlated with alcohol or drug dependency per se in the mothers than with mental illness.     

The economic burden of schizophrenia in the United States in 2002

OBJECTIVE: This study quantifies excess annual costs associated with schizophrenia patients in the United States in 2002 from a societal perspective. METHOD: Annual direct medical costs associated with schizophrenia were estimated separately for privately (N = 1090) and publicly (Medicaid; N = 14,074) insured patients based on administrative claims data, including a large private claims database and the California Medicaid program (MediCal) database, and compared separately to demographically/geographically matched control samples (1 case:3 controls). Medicare costs of patients over age 65 years were imputed using the Medicare/MediCal dual-eligible patients (N = 1491) and published statistics. Excess annual direct non-health care costs were estimated for law enforcement, homeless shelters, and research/training related to schizophrenia. Excess annual indirect costs were estimated for 4 components of productivity loss: unemployment, reduced workplace productivity, premature mortality from suicide, and family caregiving using a human capital approach based on market wages. All costs were adjusted to 2002 dollars using the Medical Care Consumer Price Index and were based on the reported prevalence in the National Comorbidity Survey Replication. RESULTS: The overall U.S. 2002 cost of schizophrenia was estimated to be $62.7 billion, with $22.7 billion excess direct health care cost ($7.0 billion outpatient, $5.0 billion drugs, $2.8 billion inpatient, $8.0 billion long-term care). The total direct non-health care excess costs, including living cost offsets, were estimated to be $7.6 billion. The total indirect excess costs were estimated to be $32.4 billion. CONCLUSION: Schizophrenia is a debilitating illness resulting in significant costs. The indirect excess cost due to unemployment is the largest component of overall schizophrenia excess annual costs.     

Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder

BACKGROUND: A collaborative care (CC) intervention for patients with panic disorder that provided increased patient education and integrated a psychiatrist into primary care was associated with improved symptomatic and functional outcomes. This report evaluates the incremental cost-effectiveness and potential cost offset of a CC treatment program for primary care patients with panic disorder from the perspective of the payer. METHODS: We randomly assigned 115 primary care patients with panic disorder to a CC intervention that included systematic patient education and approximately 2 visits with an on-site consulting psychiatrist, compared with usual primary care. Telephone assessments of clinical outcomes were performed at 3, 6, 9, and 12 months. Use of health care services and costs were assessed using administrative data from the primary care clinics and self-report data. RESULTS: Patients receiving CC experienced a mean of 74.2 more anxiety-free days during the 12-month intervention (95% confidence interval [CI], 15.8-122.0). The incremental mental health cost of the CC intervention was $205 (95% CI, -$135 to $501), with the additional mental health costs of the intervention explained by expenditures for antidepressant medication and outpatient mental health visits. Total outpatient cost was $325 (95% CI, -$1460 to $448) less for the CC than for the usual care group. The incremental cost-effectiveness ratio for total ambulatory cost was -$4 (95% CI, -$23 to $14) per anxiety-free day. Results of a bootstrap analysis suggested a 0.70 probability that the CC intervention was dominant (eg, lower costs and greater effectiveness). CONCLUSION: A CC intervention for patients with panic disorder was associated with significantly more anxiety-free days, no significant differences in total outpatient costs, and a distribution of the cost-effectiveness ratio based on total outpatient costs that suggests a 70% probability that the intervention was dominant, compared with usual care.     

Estimated cost of treating myasthenia gravis in an insured U.S. population

Introduction: In this study we estimated the costs paid by U.S. health plans for treating myasthenia gravis (MG) in 2009 and determined the major cost drivers. Methods: One hundred thirteen MG patients were matched by propensity scores with 339 non‐MG patients from a comprehensive health‐care insurance database. The mean annual costs paid by the health plan for treating MG, costs by place of service, and costs for intravenous immunoglobulin (IVIg) and plasma exchange were determined. Results: Mean annual costs paid by the health plan per MG patient were $20,190 (SEM $4,763) and costs attributable to treating MG were $15,675. Home health services accounted for 23% of MG patient costs and represented almost exclusively IVIg infusion costs. Six MG patients had a total of 136 outpatient IVIg infusions at an average annual cost of $109,463 ± $57,303. Conclusions: The estimated annual health plan paid costs for treating MG were $15,675. Home health services represented 23% of MG patient costs, largely driven by IVIg administration. Muscle Nerve, 2012     

Cost and cost-effectiveness of hospital vs residential crisis care for patients who have serious mental illness

BACKGROUND: This study evaluates the cost and cost-effectiveness of a residential crisis program compared with treatment received in a general hospital psychiatric unit for patients who have serious mental illness in need of hospital-level care and who are willing to accept voluntary treatment. METHODS: Patients in the Montgomery County, Maryland, public mental health system (N = 119) willing to accept voluntary acute care were randomized to the psychiatric ward of a general hospital or a residential crisis program. Unit costs and service utilization data were used to estimate episode and 6-month treatment costs from the perspective of government payors. Episodic symptom reduction and days residing in the community over the 6 months after the episode were chosen to represent effectiveness. RESULTS: Mean (SD) acute treatment episode costs was $3046 ($2124) in the residential crisis program, 44% lower than the $5549 ($3668) episode cost for the general hospital. Total 6-month treatment costs for patients assigned to the 2 programs were $19,941 ($19,282) and $25,737 ($21,835), respectively. Treatment groups did not differ significantly in symptom improvement or community days achieved. Incremental cost-effectiveness ratios indicate that in most cases, the residential crisis program provides near-equivalent effectiveness for significantly less cost. CONCLUSIONS: Residential crisis programs may be a cost-effective approach to providing acute care to patients who have serious mental illness and who are willing to accept voluntary treatment. Where resources are scarce, access to needed acute care might be extended using a mix of hospital, community-based residential crisis, and community support services.