What should non‐US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s

Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic-related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health-care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health-care spending through independent management, starting with diagnostic procedure code or diagnostic-related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.     

Metabolic effects and cost-effectiveness of aripiprazole versus olanzapine in schizophrenia and bipolar disorder

Kasteng F, Eriksson J, Sennfält K, Lindgren P. Metabolic effects and cost‐effectiveness of aripiprazole versus olanzapine in schizophrenia and bipolar disorder. Objective: To assess the cost‐effectiveness of aripiprazole versus olanzapine in the treatment of patients with schizophrenia or bipolar disorder in Sweden with focus on the metabolic impact of the treatments. Method: A Markov health‐state transition model was developed. The risks of developing metabolic syndrome after one year of treatment with aripiprazole or olanzapine were derived from a pooled analysis of three randomised clinical trials. The subsequent risks of developing diabetes or coronary heart disease were based on previously published risk models. A societal perspective was applied, adopting a lifetime horizon. Univariate and probabilistic sensitivity analyses were conducted. Results: Treatment with aripiprazole dominates over olanzapine in both schizophrenia and bipolar disorder. In schizophrenia, quality‐adjusted life‐years (QALYs) gained were 0.08 and cost savings Swedish kronor (SEK) 30 570 (USD 4000); in bipolar disorder, QALYs gained were 0.09 and cost savings SEK 28 450 (USD 3720). In probabilistic sensitivity analyses, aripiprazole resulted in a dominant outcome in 84% of cases in schizophrenia and in 77% of cases in bipolar syndrome. Conclusion: The significantly lower risk of developing metabolic syndrome observed with aripiprazole compared with olanzapine is associated with less risk of diabetes and cardiovascular morbidity and mortality that translates into lower overall treatment cost and improved quality of life over time.     

Medicaid,health care financing trends,and the future of state-based public mental health services

Medicaid now funds more than half of public mental health services administered by states and could account for two-thirds of such spending by 2017. This trend and others represent a major shift in the predominant model by which public mental health services are funded, organized, and delivered. One model is associated with programs administered by state mental health authorities and is characterized by direct funding of designated community providers. This model is being displaced by one associated with state Medicaid programs, which are based on organization and financing methods characteristic of health insurance plans. This shift in models encompasses issues such as administrative authority, funding source, data collection, population served, services provided, and attitudes toward providers and consumers. Failure to understand these changes and their implications will probably have negative consequences.     

Self‐reported use of mental health services versus administrative records: care to recall?

Estimates of the level of unmet need for mental health treatment often rely on self-reported use of mental health services. However, depressed persons may over-report their use in relation to administrative records if they are highly distressed. This study seeks to replicate and explicate the finding that persons at a high level of distress report more mental health service use than recorded in their healthcare records. The study sample, N = 36,892, 12 years and older, was drawn from the 1996/97 Ontario portion of the Canadian National Population Health Survey. Respondents were individually linked to their administrative mental healthcare records 12 months backward in time. Of these, 96.5% agreed to the link and 23,063 (62.5%) were linked. Almost two-thirds of those who were depressed in the past year were currently at a high level of distress. Differential reporting of use for highly distressed persons in excess of 100% remained in the use of different types of physician providers after adjustments for other potential determinants of use. Telescoping was also not an explanation. The patterns of differential reporting between groups expected to diverge and converge in their recall ability were consistent with a recall bias. As this study was not able to rule out a recall bias, it further accentuates concerns about the impact of bias in the measurement of mental health-service use and inferences made concerning the determinants of use.     

Pharmacoeconomic studies of antidepressants: focus on venlafaxine

Newer antidepressants are more expensive in terms of acquisition costs than older drugs. However, cost effectiveness simulations and retrospective analyses of administrative databases of newer antidepressants, including venlafaxine, suggest that the higher acquisition costs may be offset or more than offset by savings of other treatment costs. Because simulations and retrospective studies are vulnerable to multiple methodologic uncertainties, large scale randomized "real-world" cost effectiveness experiments are needed. If venlafaxine in actual practice is more effective or has a more rapid onset of action than SSRIs as suggested by efficacy studies and existing meta-analyses, these effects could translate into pharmacoeconomic advantages.     

Cost of Epilepsy in the United States: A Model Based on Incidence and Prognosis

Summary: A model of the clinical course of epilepsy from onset until remission or death has been developed for six prognostic groups, including survival, use and cost of medical care, and time lost from work and housekeeping. The model has been used to generate preliminary estimates of the lifetime cost of epilepsy for a cohort of persons diagnosed in 1990 in the United States. The distribution of incident cases among prognostic groups is derived from epidemiologic studies of prognosis in epilepsy. Direct cost is estimated by multiplying nationally representative unit costs by the expected type and frequency of medical care use. The latter were derived by an expert panel, based on inferences from existing literature and on their own clinical experiences. Indirect cost is estimated based on lost earnings associated with projections of restricted activity days, excess unemployment, and excess mortality. Total lifetime cost in 1990 dollars of all persons with epilepsy onset in 1990 was estimated at $3.0 billion, with indirect cost accounting for 62% of the total. Cost per patient ranged from $4,272 for persons with remission after initial diagnosis and treatment to $138,602 for persons with intractable and frequent seizures. Antiepileptic drug (AED) treatment is the most costly category of service. Different assumptions about the amount and type of drug administration cause major changes in overall cost estimates.     

The Integration of Primary Care and Behavioral Healthcare in Northern California Kaiser-Permanente

Integration of behavioral healthcare and primary care has a number of presumed benefits, including better communication between providers and systems, leading to improved patient care. There are studies showing medical cost offsets, although they tend to be in circumscribed research settings. Northern California Kaiser-Permanente has designed a new primary care system providing mental health clinicians on a primary care team. Those clinicians evaluate patients, create treatment plans, provide brief interventions, coordinate care with specialty behavioral healthcare, and consult with primary care physicians. Those physicians also have an increased role in the detection and treatment of behavioral health problems via guidelines developed with behavioral health. Structural changes within the overall system, including regional call centers and computerized clinical information systems, support the integration. Quality programs also support the ongoing improvement of the integration process. There are investment expenses in this type of re-design, but also expected cost savings. An infrastructure is now in place to measure both clinical outcomes, and cost effects of the new model.     

Treatment Outcome,Duration, and Costs: A Comparison of Performance Indicators Using Data from Eight Mental Health Care Providers in The Netherlands

Assessing performance of mental health services (MHS) providers merely by their outcomes is insufficient. Process factors, such as treatment cost or duration, should also be considered in a meaningful and thorough analysis of quality of care. The present study aims to examine various performance indicators based on treatment outcome and two process factors: duration and cost of treatment. Data of patients with depression or anxiety from eight Dutch MHS providers were used. Treatment outcome was operationalized as case mix corrected pre-to-posttreatment change scores and as reliable change (improved) and clinical significant change (recovered). Duration and cost were corrected for case mix differences as well. Three performance indicators were calculated and compared: outcome as such, duration per outcome, and cost per outcome. The results showed that performance indicators, which also take process variability into account, reveal larger differences between MHS providers than mere outcome. We recommend to use the three performance indicators in a complementary way. Average pre-to-posttreatment change allows for a simple and straightforward ranking of MHS providers. Duration per outcome informs patients on how MHS providers compare in how quickly symptomatic relief is achieved. Cost per outcome informs MHS providers on how they compare regarding the efficiency of their care. The substantial variation among MHS providers in outcome, treatment duration and cost calls for further exploration of its causes, dissemination of best practices, and continuous quality improvement.     

Economic impact of services for first-episode psychosis: a decision model approach

Aim: To assess the impact of early intervention (EI) services on service costs for people with first‐episode psychosis. Methods: A decision model was constructed to map the care pathways following input from EI services and from standard care. A Markov process was used to run the model over 18 2‐month cycles. Probabilities and costs for the model of admissions, readmissions and use of community services were obtained from the literature, routine sources and expert opinion. One‐way and probabilistic sensitivity analyses were conducted to address uncertainty around the parameter estimates. Results: The model estimated 1 year costs to be £9422 for EI and £14 394 for standard care. The respective figures over 3 years were £26 568 and £40 816. One‐way sensitivity analyses revealed that the results were robust to changes in most parameters with the exception of the readmission rate. A relatively small decrease in the readmission rate for standard care patients would eliminate the cost saving. The probabilistic sensitivity analyses also showed that the results were robust to parameter changes. Conclusions: This study suggests cost savings associated with EI. However, caution is required as the model is relatively simple and relies on a number of assumptions.     

Derivation and analysis of basic computational operations of thalamocortical circuits

Shared anatomical and physiological features of primary, secondary, tertiary, polysensory, and associational neocortical areas are used to formulate a novel extended hypothesis of thalamocortical circuit operation. A simplified anatomically based model of topographically and nontopographically projecting ("core" and "matrix") thalamic nuclei, and their differential connections with superficial, middle, and deep neocortical laminae, is described. Synapses in the model are activated and potentiated according to physiologically based rules. Features incorporated into the models include differential time courses of excitatory versus inhibitory postsynaptic potentials, differential axonal arborization of pyramidal cells versus interneurons, and different laminar afferent and projection patterns. Observation of the model's responses to static and time-varying inputs indicates that topographic "core" circuits operate to organize stored memories into natural similarity-based hierarchies, whereas diffuse "matrix" circuits give rise to efficient storage of time-varying input into retrievable sequence chains. Examination of these operations shows their relationships with well-studied algorithms for related functions, including categorization via hierarchical clustering, and sequential storage via hash- or scatter-storage. Analysis demonstrates that the derived thalamocortical algorithms exhibit desirable efficiency, scaling, and space and time cost characteristics. Implications of the hypotheses for central issues of perceptual reaction times and memory capacity are discussed. It is conjectured that the derived functions are fundamental building blocks recurrent throughout the neocortex, which, through combination, gives rise to powerful perceptual, motor, and cognitive mechanisms.     

Improving Integrated General Medical and Mental Health Services in Community-based Practices

The historical fragmentation of physical and mental health services has impeded efforts to improve quality and outcomes of care for persons with mental disorders. However, there is little information on effective strategies that might reduce fragmentation and improve integrated services within non-academic, community-based healthcare settings. Twenty-three practices from across the U.S. participated in a learning community meeting designed to identify barriers to integrated care and strategies for reducing such barriers. Barriers were initially identified based on a quantitative survey of organizational factors. Focus groups were used to elaborate on barriers to integrated care and to identify strategies for reducing barriers that are feasible in community-based settings. Participants identified key barriers, including administrative (e.g., lack of common medical records for mental health and general medical conditions), financial (e.g., lack of reimbursement codes to bill for mental health and general medical care in the same setting), and clinical (e.g., lack of an integrated care protocol). Top strategies recommended by participants included templates (i.e., for memoranda of understanding) to allow providers to work across practice settings, increased medical record security to enable a common medical record between mental health and general medical care, working with state Medicaid agencies to establish integrated care reimbursement codes, and guidance in establishing workflows between different providers (i.e., avoid duplication of tasks). Strategies to overcome barriers to integrated care may require cooperation across different organizational levels, including administrators, providers, and health care payers in order for integrated care to be established and sustained over time.     

The emotional toll of spousal morbidity and mortality.

OBJECTIVE: Spouse caregivers have an increased risk of mental and physical illness during caregiving and widowhood. The authors sought to evaluate whether partners of an ill spouse have a higher likelihood of developing mental health or substance abuse (MHSA) disorders than partners who have healthy spouses, accounting for both spousal illness and death. METHODS: The authors used Medicare claims from 1993-2001 for 474,228 married couples. The authors used Cox models to determine the effect of spouse illness on partner MHSA diagnosis, controlling for demographic and clinical characteristics. RESULTS: A wife's hospitalization increased the husband's risk of MHSA diagnosis by 1.29 (95% confidence interval [CI]: 1.28-1.29) and his risk of depression by 1.49 (95% CI: 1.48-1.51). A husband's hospitalization increased the risk of a wife's MHSA diagnosis by 1.33 (95% CI: 1.32-1.33) and her risk of depression by 1.41 (95% CI: 1.39-1.42). A wife's death increased the risk of the husband's MHSA diagnosis by 1.12 (95% CI: 1.11-1.13) and increased his risk of depression by 1.49 (95% CI: 1.46-1.51). A husband's death increased the risk of the wife's MHSA diagnosis by 1.14 (95% CI: 1.14-1.15) and increased her risk of depression by 1.41 (95% CI: 1.39-1.42). CONCLUSION: Spouse hospitalizations and spouse death independently increase the risk for partner MHSA and depression diagnoses. These findings can identify which individuals are at greatest risk for emotional distress and should be targeted for interventions to relieve caregiver burden that can arise separately and additively from both spousal illness and death.     

Perceived Impact by Administrators of Psychiatric Emergency Services after Changes in a State’s Mental Health System

As a safety net, psychiatric emergency services are sensitive to system changes. To determine the impact of a state’s changes in its mental health system, administrators of publicly funded psychiatric emergency services were surveyed. They reported few (M=0.8) negative changes in coordination of care but 77% endorsed change in administrative burden (54% saying it negatively affected quality of services). Reporting negative effect of administrative burden was associated with treating more persons with substance abuse problems and greater challenge posed by distance to local providers. These results suggest that impact of state-level changes was not uniform but associated with local characteristics.Cynthia L. Arfken, Lori Lackman Zeman, and Alison Koch are affiliated with the Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, USAThe data were presented as a poster at Institute on Psychiatric Services, Atlanta GA, October 2004.     

Uptake and Costs of Care for Epilepsy: Findings from a U.K. Regional Study

Summary: Purpose: Epilepsy is a common neurological condition, with significant resource implications for the health services, but few studies to date have examined the uptake and costs of care for this condition. As part of a large prevalence study of epilepsy conducted in one U.K. Health Region, we investigated both direct and indirect costs of epilepsy care and measured and valued the direct costs.
Methods: Data about service use were obtained from primary physician records and patient questionnaires. Unit costs for each item of resource use were generated from several sources.
Results: The greatest direct health care cost is that of hospital-based care. Pharmaceutical services also represent a significant element of the cost of epilepsy, the financial costs of prescribing newly developed antiepileptic drugs (AEDs) being large relative to those of the older drugs; therefore, the benefits derived from their use must be carefully assessed. The importance of good seizure control is amply illustrated by the findings about the differential costs associated with epilepsy of varying severity. The direct costs of caring for people with poorly controlled epilepsy are significant, with more than half the total cost of epilepsy care accounted for by patients with frequent seizures even though this group represented only a quarter of all patients in the present study.
Conclusions: Our data emphasize the importance of optimizing seizure control as a means of reducing the costs of epilepsy, not only to the person with the condition, but also to society.     

The relationship between treatment access and spending in a managed behavioral health organization.

OBJECTIVE: This study replicated an earlier study that showed a linear relationship between level of treatment access and behavioral health spending. The study reported here examined whether this relationship varies by important characteristics of behavioral health plans. METHODS: Access rates and total spending over a five- to seven-year period were computed for 30 behavioral health plans. Regression analysis was used to estimate the relationship between access and spending and to examine whether it varied with the characteristics of benefit plans. RESULTS: A linear relationship was found between level of treatment access and behavioral health spending. However, the relationship closely paralleled that found in the earlier study only for benefit plans with an employee assistance program linked to the managed behavioral health organization and for plans that do not allow the use of out-of-network providers. CONCLUSIONS: The results of this study replicate those of the earlier study in showing a linear relationship between access and spending, but they suggest that the magnitude of this relationship may vary according to key plan characteristics.     

Cost-effectiveness of an Internet-based aftercare intervention after inpatient treatment in a psychosomatic hospital

Abstract

Objective: The implementation of new interventions into routine care requires the demonstration of both their effectiveness and cost-effectiveness. Method: We explored the cost-effectiveness of an Internet-based aftercare program in addition to treatment as usual (CHAT) which was compared to treatment as usual (TAU) following inpatient treatment. Incremental cost-effectiveness ratios were calculated based on cost of the intervention, cost of outpatient treatment, and remission rates within 1 year after discharge from hospital. Results: Assuming a willingness-to-pay of an additional 14.87 € per treatment for every additional percent of remission, CHAT was cost-effective against TAU at a 95% level of certainty. Cost per remission equaled 2664.84 € in TAU and 1752.75 € in CHAT (34.2% savings). Conclusions: This is the first evidence that Internet-based aftercare may enhance long-term treatment outcome in a cost-effective way.