Treatment Of Depression In Managed Care

Mark Mays, James W. Croake, Mark Mays, James W. Croake

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135062606
• Edition: 1
• Topic: Medicine
• Subtopic: General Health

Published in 1997, Treatment of Depression in Managed Care is a valuable contribution to the field of Psychiatry/Clinical Psychology.

1

Managed Care

Managed care is the new environment in which mental health care is being delivered. In biology, environments determine which species flourish and thrive, and which species dwindle and decline. Harsh environmental changes may cause some species to disappear altogether, as has the dinosaur, and as might the snail darter. Ecological environments nurture and support certain species, but not others. Some species thrive on what an environment provides, and others cannot adapt to the sustenance available. Survival is a dance between the environment and the organism, where compatibility defines survival.

This applies to health care as well. Managed care has become the environment and determines the ecology for the delivery of health care services. Some “species” of mental health care will flourish, and others will fade. As an environment, managed care supports those approaches which focus on change, value efficiency, define goals, allow flexibility of treatment approach, and achieve measurable results. Theories and therapies in mental health which support those treatment approaches will grow. Other therapies are less concerned with measurable results and embrace more subjective and intrapsychic changes. Some therapies propose treatment approaches which may take years as they strive to explore character restructuring and the modification of global patterns of personal organization in the context of a slowly evolving therapeutic relationship. Perhaps sadly, these theories will not be compatible with the new health care milieu and will not gain the reimbursement necessary to continue.

The community of mental health professionals has been attentive to the changes that are occurring with the increased involvement with managed care. Articles discuss “coping” with managed care. Focus groups, such as that conducted in 1994 by the American Psychological Association (APA, 1994), show concerns and complaints about managed care which “cut across all focus groups.” As was noted, “almost universally, the participants expressed regret about what they believe will be the ultimate impact of managed care on their patients and themselves.” Managed care is seen by many, particularly those with a psychoanalytical point of view, in themes reminiscent of mourning. Others see the changes as oppressive and compare managed care to a “totalitarian regime” (Shore, 1995). Fox (1995) discusses the “rape of psychotherapy.” Others employ a metaphor of war and write about “battling” with managed care. The old way of doing things seems to be on its last legs, and a sense of loss, fear, and anger characterizes the mood of the provider community.

It also seems quite clear that managed care is here, and here to stay. Managed care membership has increased. Up to 90% of those Americans receiving mental health care benefits will receive these services through managed care organizations or arrangements by the year 2000 (Freeman, 1995). In its 1992 survey, Psychotherapy Financesfound that 66% of interviewed therapists had already signed managed care contracts. Be they Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Employee Assistance Programs (EAPs), Competitive Medical Plans (CMPs), Independent Practice Associations (IPAs), or “carve-out plans” such as those administered by Greenspring or U. S. Behavioral Health, such organizations, acronyms, and arrangements will continue to be the context of mental health delivery in the future.

These changes will have profound effects on the mental health professions. Cummings (1986), long recognizing the proliferation of mental health costs and therapists, discussed the trends accompanying these excesses many years ago. Actuarial predictions of efficient utilization, such as that achieved in managed care, indicate the need for perhaps one qualified therapist for every 5,000 people. This would create the need for approximately 50,000 psychiatrists, psychologists, social workers, and mental health counselors for the 250 million people in the United States. At present there are approximately 250,000 such therapists licensed and certified in the United States, a ratio of about 1 per 1,000 people. Many predict that up to 50% of all currently practicing psychotherapists will be out of business by the year 2000 (e.g., Cummings, 1988; Freeman, 1995). There are those who see the fee-for-service private-pay arena that has characterized mental health for the past 30 years as passing away. They are not just imagining its death.

Why Managed Care?

Managed care is a solution to a problem, and the problem it is attempting to solve is real. Some health care costs have increased by two to three times the national inflation rate over the past 10 years (Berman, 1987). Although there are some indications that this is slowing, the trend is still alarming. Particularly when costs of health care in the United States are compared with health care costs in other countries, the trend is a cause for concern. For example, in the 1980s the average annual expenditure for health care costs in the United States exceeded 1,900 per person, as compared to $500 per person in Japan and $400 per person in England (Ludwigsen and Enright, 1988). Japan spends 6.7% of its Gross National Product (GNP) on health care, with outcome measures comparable to those of the United States. At present, health care costs in the United States exceed 12% of the GNP and are projected to escalate to well over 15% of the GNP by the year 2000 (Davies and Felder, 1990). If costs continue to rise at the current rate, health care costs could consume the entire GNP of the United States by the early decades of the next century. Cummings (1995a) notes that all 250 million Americans could receive health care in 38 megaorganizations the size and efficiency of the Kaiser Permanente HMO, but requiring only 290,000 physicians (half the number in practice today) and at a cost of only 5% of the GNP.

Mental health care costs have also increased. In one year alone, corporate giant GTE’s outpatient costs for mental health increased 46%. Mental health costs have increased to over 15% of the total health care budget. The number of mental health therapists has also increased radically. The largest group of treating therapists are at the Master’s level. This group has grown to constitute a population of over 130,000 currently licensed in counseling or social work. New graduates are being produced at the rate of over 5,000 per year from over 500 programs. Not only are there more therapists than in years gone by, but more people are seeing therapists. Session lengths have increased, and the cost per visit has risen in the private-pay world. Utilization has increased far beyond what would be expected by assessment of risk or epidemiological studies. There is no question but that something needs to changed.

Managed care is a response to these issues by policy makers, patients, and purchasers of health care resources who are concerned about cost, access, and the quality of those services. It is an attempt to reduce health care costs by using resources in a deliberate way while simultaneously ensuring access to and quality of care. Managed care today takes several forms. Health Maintenance Organizations, or HMOs, are the oldest example of managed care structures, dating back to the early 1900s with the formation of the precursors to still operating plans such as Kaiser Permanente in California and Group Health in Washington. DeLeon, VandenBos, and Bulatao (1991) observe that until the 1980s the terms “managed care” and “HMO” could be used interchangeably. Today these plans offer a range of outpatient and inpatient medical and mental health services to an enrolled population for a per-person amount settled in advance, known as a “capitated rate.”

Many other forms of managed care followed in the 1980s. Preferred Provider Organizations, or PPOs, were formed to offer financial incentives to consumers who select a limited group of “preferred” providers of services at a reduced rate of reimbursement. Employee Assistance Programs (EAPs) for acutely distressed workers and Competitive Medical Plans (CMPs) for Medicare beneficiaries also evolved and provided limited mental health services. Other structures exist, and many others will develop, but all will attempt to use management concepts of control and deliberate use of limited resources.

The scope of managed mental health care has increased due to traditional fee-for-service private-pay insurance plans adopting managed care programs. In contrast with the old fee-for-service reimbursement arrangements, managed care today has a variety of manifestations. The “first generation” of managed care networks in mental health were “carved out” of the benefits packages of insurance companies and administered separately by managed care organizations or companies. These intermediary managed care companies would ensure that treatment was in fact necessary and authorize services to providers who had been reviewed and credentialed. Treatment was often authorized for a fixed number of sessions, and preauthorization for services was required. Utilization review, credentialing, and monitoring of patient satisfaction were frequently functions of these organizations. This gatekeeper and monitoring role evoked much protest from the provider community. The American Psychological Association member focus groups revealed a number of concerns about confidentiality, limitation of treatment judged necessary, and review by managed care staff who were seen as less knowledgeable than the provider to make health care decisions.

Carve-out systems still exist, but there has emerged a second generation system known as “provider care organizations,” a form of practice association with the capability of contracting for care. These groups may have a number of different disciplines in a linked practice, and they may conduct provider monitoring and quality assurance activities internally. They may even contract with managed care organizations, health maintenance organizations, or other groups. These organizations have taken a number of forms, and it can only be assumed that they will continue to evolve. In fact, a very strong argument can be made that the next few years will see only “transitional” delivery systems, which may bear a faint resemblance to later and more effective forms of medical and mental health delivery. Many, such as Cummings (1995b), predict the ultimate demise of carve-out systems. Various forms of managed care will almost certainly unfold to target economic goals through various practice structures, but care will almost certainly be managed.

The future of health care is very hard to predict, and the exact form that managed care will take will probably be determined by the creativity of therapists, researchers, and managers; interpretations of other public policy issues which might be reflected in laws and regulations, such as antitrust law; studies persuasive to purchasers of health care or insurance companies regarding the cost savings of providing mental health care; and other such variables, including chance. Although the specific form or manifestation of managed care is hard to predict, however, one can make some reasonable predictions for trends that will likely be reflected in whatever organizational structures unfold.

Mental health care is likely to be increasingly delivered in an organized health care marketplace by provider groups, often integrated with medical care (Drum, 1995). There is likely to be an increasing emphasis on capitation, which is the reimbursing of groups for providing mental health services on a cost-per-capita basis. Capitated systems do not reimburse providers for units of treatment which are delivered in response to a mental health problem. Instead, groups of providers are paid a fixed amount for each member of that patient population, whether they require care or not. The provider group is then charged with the responsibility of providing care, regardless of utilization. Capitated systems tend to limit costs to the purchasers of health care insurance, and many see them as vehicles for increasing the creativity of the providers of such services. Capitated systems are seen as rewarding providers for efficient delivery of services, in contrast to unregulated reimbursement for services provided, which is thought to reward inefficiency.

Contracts for service delivery will almost certainly be with organizations, such as provider groups, and not with individual providers. A patient will turn to an organization for care rather than being referred to an individual provider. That organization will have the responsibility for providing the appropriate level and duration of care. Care may involve the use of specialists for such interventions as medication, psychotherapy, health education, or family treatment. It is quite conceivable that half a dozen providers could respond to an individual’s personal and family problems, particularly if these problems compromise medical functioning. Treatment will be team treatment, on both the contract and the delivery level. It should be kept in mind, however, that the managed care provider group members will need to be linked through communication and information networks, not necessarily by physical proximity.

Quality assurance efforts will be a vital component of managedcare efforts. Quality assurance programs are essential, particularly with capitated systems, which might reward providers for maintaining rates of utilization which are lower than necessary and appropriate. Provider evaluations may address patient satisfaction, rate of therapeutic success, utilization rates, and peer assessments. Less sophisticated programs may assess such things as number of rings until a phone is answered and the giving of directions to an office, all easy to measure but of questionable relevance.

Not All of this is Bad News

Not all of these changes are necessarily “bad news.” While there has been much provider distress, there has been no indication that managed care lowers the quality of care provided. In fact, if accessibility to care is considered one of the criteria of effective health care, managed care can help resolve the dilemma of inaccessibility to care for those tens of millions currently unable to receive any mental health care. It has also been argued that with the escalating cost of care, access to conventional care would be increasingly limited on an economic rather than a rational basis.

Purchasers of managed health care programs have been happy with the results. Surveys assessing the effectiveness of managed care show cost savings (Curtiss, 1989). Compulsory utilization review has been found to reduce the rate of hospitalization, length of stay once admitted, and overall medical costs (Burton, Hoy, Bonin, and Gladstone, 1989). The ratio of cost savings for such managed care efforts is also high. Feldstein, Wickizer, and Wheeler (1988) found that for every dollar spent on cost containment, there was an $8 savings in overall medical costs. The proportion of administrative costs of health care is far greater in the United States than in other countries, in some cases by as much as twice as high (Woolhandler and Himmelstein, 1991), but few complain about these administrative programs, which bring about an eight-to-one level of savings.

Although quality of care is hard to measure, satisfaction with care is not. Studies show great satisfaction with managed care programs. A majority of both union and corporate leaders surveyed found that the majority detected no change in quality, only about one in eight thought it to have declined, and more than a quarter thought quality had improved (Alvine, 1989). While some studies evaluate satisfaction with overall health care and do not focus or select out mental health care, most patients and purchasers seem content with the overall changes which are taking place in health care delivery.

Although the mood in the provider community seems grim, some note an opportunity with this amount of change. Nicholas Cumrnings (1995a) views this as a time of “golden opportunity” for those with creativity and energy. There are other bright spots from the provider’s point of view, chief among them that mental health services are now included in most health care policies and most proposals for health care reform. Mental health care is acknowledged to serve not only the needs of the individual patient, but also to further other societal goals.

One of the benefits of effective provision of mental health care is the reduction in costs on the primary medical care level. Many studies have shown that appropriately provided outpatient mental health services reduce the utilization of more expensive medical and surgical services. This results in an overall decrease in health care expenditures (e.g., Hankin, Kessler, and Goldberg, 1983; Borus and Olendzki, 1985). These findings have been reported for a number of populations: high medical utilizers who are not experiencing life-threatening illnesses, medical patients with severe illness, patients diagnosed with a major mental disorder, and entire populations receiving health care benefits which include mental health coverage. Many believe that this cost offset is sufficiently great that mental health care, in effect, pays for itself.

The “Hawaii Medicaid” project (Cumrnings, Dorken, Pallak, and Henke, 1990) targeted high medical utilizers with a program designed to help them solve life problems and build social support, using psychotherapy as way to coordinate these efforts. Compared to a matched control group, those receiving these services reduced medical utilization by over $4 million. Similarly, Tulkin, Frank, Bernstein, Aubel, and Lehn (1992) found that a chronic pain program produced a reduction in medical utilization of over 40%. Although these studies are not conclusive, they do point to hopeful possibilities for justifying expanded outpatient mental health services aimed at populations of high medical utilizers.

Perhaps a different way to view the same population, or phenomenon, is to examine the medical utilization rates of those with diagnosed psychological disorders. Katon, Ries, and Kleinman (1984), in a study of primary care patients, found that 18% scored in the moderate-to-severe range for depression on two different rating scales. Follow-up studies showed that this group made more than twice the number of medical visits, called more often, and received more diagnostic testing than nondepressed cohorts. Katon observed that not all depressed patients were high medical utilizers, however. Some who were depressed never returned after the initial visit. Those who did return used the services very extensively. In another study, Katon and Sullivan (1990) demonstrated that over half of medical high utilizers in a large sample scored well into the clinical range on a screening test of psychiatric symptoms. Almost three quarters of the high utilizers had symptoms suggestive of a somatization disorder. Kessler, Steinwachs, and Hankin (1982) demonstrated that those receiving psychiatric care also reduced medical utilization significantly, with effects continuing for up to two years after completion of psychiatric intervention. Eisenberg (1992), writing in The New England Journal of Medicine, concludes that “between 11-36% of all general care physician visits involved patients with diagnosable psychiatric disorders.”

The studies show that even those with serious physical illness can realize cost savings in their medical care with the addition of mental health services. Belar (1991) showed that offering mental health services to those with medical conditions such as diabetes, hypertension, and even cardiac disease results in improved morbidity rates, reduced hospital readmission rates, and better medical compliance than for those not receiving mental health benefits. Lechnyr (1992) found these medical cost savings to be as high as 18 to 31%.

Research also shows that more than 70% of the cost of mental health services goes to inpatient services (e.g., Ackley, 1993). Studies have demonstrated that provision of outpatient services can dramatically reduce the risk of more expensive hospitalization with no increase in patient risk. Mays (1979) found that offering outpatient services in a very accessible way reduced inpatient utilization to less than 25% of that predicted by actuarial studies. CHAMPUS increased its outpatient costs from $81 million to $103 million between 1989 and 1990, but reduced inpatient utilization as a result to the point of achieving a net gain of $200 million in overall cost reductions (Psychiatric Times, August 1993).

Estimates of potential savings from accessible and effective mental health care are dramatic. The National Institutes of Mental Health (NIMH) released a study (Goodwin and Moskowitz, 1993) which found that providing reimbursement for mental health care to the same degree as for medical care would cost $6.5 billion, but result in a savings of $8.7 billion. These estimates do not even take into account the nonmedical costs to society for mental and emotional disorders. Kamlet (1990) estimates that in 1990 major depression ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• 1. Managed Care
• 2. A Brief Primer on Brief Therapy
• 3. Theories of Depression
• 4. Diagnosis of Depression and Depressive States
• 5. Assumptions About Treatment of Depression
• 6. Treatment of Depression in the New Ecology
• 7. Treatment for Major Depression
• 8. Treatment for Less Severe Mood Disorders
• 9. Special Populations: Children and the Elderly
• 10. Special Problems: Dual Diagnosis, Refractory Depression, and Suicide
• Conclusion
• References
• Name Index
• Subject Index