Search

Objective: This study evaluated whether access to and engagement in substance use disorder treatment has improved from 2010 to 2016., Methods: Data submitted by commercial and Medicaid health plans, representing over 163 million beneficiaries from 2010 to 2016, were analyzed., Results: For commercial plans, identification increased (from 1.0% to 1.6%, p<0.001), the initiation rate declined (from 41.9% to 33.7%, p<0.001), and the engagement rate also declined (from 15.8% to 12.1%, p<0.001). The decline in the initiation and engagement rates could not be explained by the increasing identification rates. For Medicaid plans, the identification rate increased (from 3.3% to 6.7%, p<0.001), and the initiation and engagement rates were unchanged., Conclusions: Although an increasing proportion of health plan members are being identified with substance use disorders, the majority of these individuals are not engaging in treatment.

Objective: The study examined factors associated with uptake of behavioral therapy among children with attention-deficit hyperactivity disorder (ADHD)., Methods: Insurance claims data from 2008-2014 (MarketScan) were reviewed to examine associations between behavioral therapy use and demographic, patient, family, and provider factors. The association between ADHD medication use and future uptake of behavioral therapy was examined with logistic regression adjusted for covariates found to affect behavioral therapy use., Results: Among 827,396 youths with ADHD, under 50% received any billable behavioral therapy services over the 7 years. ADHD severity, gender, region of residence, assessment year, comorbid behavioral disorders, and behavioral therapy use by siblings were significantly associated with behavioral therapy use (p<0.001). Parent psychopathology and sibling medication use was not. Children prescribed ADHD medication were 2.5 times less likely than those not prescribed medication to use behavioral therapy, even after adjustment for severity of behavioral health symptoms and other covariates (odds ratio [OR]= 0.41, 95% confidence interval [CI]=.40-.41, p<0.001). Effects of medication use were stronger for future uptake of behavioral therapy (OR=0.25, 95% CI =0.24-0.25, p<.001). The impact of medication use on behavioral therapy use was equally strong for children under age 6 and for older children and did not weaken after release of 2011 guidelines recommending behavioral therapy as the initial ADHD treatment for young children., Conclusions: Multiple systems, family, patient and provider factors affected behavioral therapy uptake. ADHD medication was a robust and potentially modifiable factor. It may be advisable to engage families in behavioral therapy prior to initiation of ADHD medication.

Objective: This study examined the performance of health plans on two HEDIS measures: metabolic monitoring of children and adolescents prescribed an antipsychotic and use of first-line psychosocial care for children and adolescents prescribed an antipsychotic for a nonindicated use. Plan characteristics and other contextual factors that may be associated with health plan performance were examined to identify potential strategies for improving care., Methods: The study population included 279 commercial and 169 Medicaid health plans that voluntarily submitted data for care provided in 2016. Bivariate associations between performance on the two measures and each plan characteristic (eligible population size, region, profit status, model type, and operating in a state with legislation on prior authorization for antipsychotics) were examined. Main-effects multivariable linear regression models were used to examine the combined association of plan characteristics with each measure., Results: Performance rates on both measures were comparable for commercial and Medicaid plans. Among commercial plans, not-for-profit plans outperformed for-profit plans on both measures. Commercial and Medicaid plans in the North performed significantly better on the metabolic monitoring measure. Commercial plans in the South and Medicaid plans in the West performed significantly worse on the first-line psychosocial care measure. Plans operating in states requiring prior authorization performed significantly better on the metabolic monitoring measure., Conclusions: This study identified key plan characteristics and other contextual factors associated with health plan performance on quality measures related to pediatric antipsychotic prescribing. Findings suggest that quality measures, in conjunction with policies such as prior authorization, can encourage better care delivery to vulnerable populations.

Objective: This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use., Methods: Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score., Results: After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions., Conclusions: Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.

Objective: Care management entity models have a positive impact on functioning and symptom control among youths with serious emotional and behavioral disorders. However, little is known about whether treatment benefits are sustained after discharge. The study objective was to examine the association between enrollment in a care management entity and mental health outcomes during the year after discharge., Methods: Data from care management entity administrative claims were linked with Medicaid claims for youths enrolled in a care management entity anytime from December 2009 through December 2013. Inverse probability treatment weighting was used to balance baseline characteristics between the youths enrolled in the care management entity and a comparison group. Study outcomes were psychiatry-related hospitalizations and emergency department (ED) visits during the year after discharge. Two models were used to compare the two groups, one modeling the probability of using any psychiatric service and one modeling the number of visits for each outcome among users of either service., Results: After adjustment with inverse probability treatment weighting, 2,381 youths (care management, N=488; comparison, N=1,893) were identified. Care management was associated with a significantly lower likelihood of any psychiatry-related ED visit (odds ratio [OR]=.65, p=.017) and any psychiatric hospitalization (OR=.60, p=.011). No significant differences in outcomes were observed when the comparison was limited to users of services., Conclusions: Reduced use of psychiatric inpatient and ED services among youths enrolled in a care management entity was sustainable after discharge. Multiagency collaboration is needed to enrich the ability to assess outcomes across broader domains.

The authors describe a quality improvement approach in which a crisis center and a payer collaborate to improve care. Each crisis visit is considered as a potentially missed opportunity for community stabilization. Daily data on crisis visits are sent to the payer for a more up-to-date analysis of trends than is possible with financial claims data, which may lag behind services provided by up to 90 days. Using these trend data, the two organizations collaborate to identify patterns that lead to opportunities for improvement and develop multiple rapid-cycle projects for better management of services, resulting in significant decreases in readmissions and in the number of high utilizers.

Objective: The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) sought to improve access to behavioral health care by regulating health plans' coverage and management of services. Health plans have some discretion in how to achieve compliance with MHPAEA, leaving questions about its likely effects on health plan policies. In this study, the authors' objective was to determine how private health plans' coverage and management of behavioral health treatment changed after the federal parity law's full implementation., Methods: A nationally representative survey of commercial health plans was conducted in 60 market areas across the continental United States, achieving response rates of 89% in 2010 (weighted N=8,431) and 80% in 2014 (weighted N=6,974). Senior executives at responding plans were interviewed regarding behavioral health services in each year and (in 2014) regarding changes. Student's t tests were used to examine changes in services covered, cost-sharing, and prior authorization requirements for both behavioral health and general medical care., Results: In 2014, 68% of insurance products reported having expanded behavioral health coverage since 2010. Exclusion of eating disorder coverage was eliminated between 2010 (23%) and 2014 (0%). However, more products reported excluding autism treatment in 2014 (24%) than 2010 (8%). Most plans reported no change to prior-authorization requirements between 2010 and 2014., Conclusions: Implementation of federal parity legislation appears to have been accompanied by continuing improvement in behavioral health coverage. The authors did not find evidence of widespread noncompliance or of unintended effects, such as dropping coverage of behavioral health care altogether.

Objective: Reducing overuse of second-generation antipsychotics among Medicaid-enrolled children is a national priority, yet little is known about how service organization affects use. This study compared differences in second-generation antipsychotic utilization among Medicaid-enrolled children across fee-for-service, integrated managed care, and managed behavioral health carve-out organizational structures., Methods: Organizational structures of Medicaid programs in 82 diverse counties in 34 states were categorized and linked to child-level cross-sectional claims data from the Medicaid Analytic Extract covering fiscal years 2004, 2006, and 2008. To approximate the population at risk of antipsychotic treatment, the sample was restricted to stimulant-using children ages three to 18 (N=419,226). The sample was stratified by Medicaid eligibility group, and logistic regression models were estimated for probability of second-generation antipsychotic use. Models included indicators of county-level organizational structure as main predictors, with sequential adjustment for personal and county-level covariates., Results: With adjustment for person-level covariates, second-generation antipsychotic use was 31% higher among youths in foster care in fee-for-service counties than for youths in counties with carve-outs (odds ratio [OR]=1.69, 95% confidence interval [CI]=1.26-2.27). Foster care youths in integrated counties had the second highest adjusted odds (OR=1.31, CI=1.08-1.58). Similar patterns of use also were found for youths eligible for Supplemental Security Income but not for those eligible for Temporary Assistance for Needy Families. Differences persisted after adjustment for county-level characteristics., Conclusions: Carve-outs, versus other arrangements, were associated with lower second-generation antipsychotic use. Future research should explore carve-out features (for example, tighter management of inpatient or restricted access, as well as care coordination) contributing to lower second-generation antipsychotic use.

Objective: The Medicare Modernization Act (MMA) specifically excluded benzodiazepines from Medicare Part D coverage starting in 2006; however, benzodiazepines are an effective, low-cost treatment for anxiety. This study evaluated the effect of the Medicare Part D benzodiazepine coverage exclusion among patients with new anxiety disorders., Methods: The authors used a quasi-experimental cohort design to study patients with new anxiety diagnoses from a large national health plan during the first six months of 2005, 2006, and 2007. Logistic and zero-truncated negative-binomial regression models using covered claims for behavioral, medical, and pharmaceutical care linked with eligibility files were used to estimate utilization and costs of psychotropic medication and health care utilization among elderly Medicare Advantage enrollees (N=8,397) subject to the MMA benzodiazepine exclusion and a comparison group of near-elderly (ages 60–64) enrollees (N=1,657) of a managed care plan., Results: Medicare Advantage enrollees diagnosed in 2005 had significantly (p<.05) higher rates of covered claims for benzodiazepines and all psychotropic drugs, lower rates of covered claims for nonbenzodiazepines, and lower expenditures for psychotropic drugs than enrollees diagnosed in 2006 and 2007. There were no significant differences over time in utilization or expenditures related to psychotropic medication among the comparison group. There also were no significant changes over time in outpatient visits for behavioral care by either cohort., Conclusions: Among elderly patients with new anxiety diagnoses, the MMA benzodiazepine exclusion increased use of nonbenzodiazepine psychotropic drugs without substitution of increased behavioral care. Overall, the exclusion was associated with a modest increase in covered claims for psychotropic medication.

Types of privately insured outpatient treatment provided by in-network practitioners were examined in a national managed behavioral health care organization to consider how practitioner type and expertise are related to diagnoses of mental disorders, substance use disorders, or both. Using 2004 practitioner credentialing, patient enrollment, and claims data, the investigators found that two-thirds of claims for psychiatrists involved medication management and two-thirds also involved psychotherapy (an overlap of about 30%). Most patients with substance use disorders saw practitioners who had specialized alcohol or drug disorder training. Claims for patients with more complex co-occurring mental and substance use disorders indicate utilization of appropriately qualified practitioners with substantial experience on average.

Objective: The study examined service use patterns by level of care in two managed care plans offered by a national managed behavioral health care organization (MBHO): an employee assistance program (EAP) combined with a standard behavioral health plan (integrated plan) and a standard behavioral health plan., Methods: The cross-sectional analysis used 2004 administrative data from the MBHO. Utilization of 11 specific service categories was compared. The weighted sample reflected exact matching on sociodemographic characteristics (unweighted N=710,014; weighted N=286,750)., Results: A larger proportion of enrollees in the integrated plan than in the standard plan used outpatient mental health and substance abuse office visits (including EAP visits) (p<.01) and substance abuse intensive outpatient or day treatment (p<.05), and the proportion using residential substance abuse rehabilitation was lower (p<.05)., Conclusions: The integrated and standard products had distinct utilization patterns in this large MBHO. In particular, greater use of certain outpatient services was observed in the integrated plan.

Objective: Managed care financing strategies that involve financial risk to insurers can reduce budgeted health expenditures. However, resource substitution may occur and negate apparent savings in budgeted expenditures. These substitutions may be important for individuals with disabling illnesses. The distribution of societal costs for adults with mental illnesses enrolled in plans that differ in their financial risk is examined to evaluate the degree to which risk-based financing strategies result in net savings or in the differential distribution of costs across public or private payers., Method: Six hundred twenty-eight adults with severe mental illnesses enrolled in three Medicaid plans that differ in financial risk arrangements were followed for 1 year to determine the distribution of resource use across Medicaid and other payers. Self-reported service use was obtained through interviews. Cost data were derived from self-reported expenditure, administrative, or agency data. Statistical procedures were used to control for preexisting group differences., Results: Managed care was associated with a tendency toward reduced overall costs to Medicaid. However, private expenditures for managed care enrollees offset decreased Medicaid expenditures, resulting in no net difference in societal costs associated with managed care., Conclusions: Understanding the distribution of societal costs is essential in evaluating health care financing strategies. For adults with mental illnesses, efforts to manage Medicaid expenditures may result in substituting individual and family resources for Medicaid services. Government must focus on the distribution of societal costs since risk-based financing strategies may redistribute costs across the fragmented human services sector and result in unintended system inefficiencies.

Of 1,969 patients seen by a clinical psychologist during 40 years of private practice, at the time the outcome data were analysed 1,374 were either in treatment or had completed treatment and all of these cases had produced outcome data. The results show that four (4) patients (0.29%) became Much Worse, 10 (0.73%) became Worse, 412 (29.96%) showed No Change, 467 (33.96%) became Better, and 482 (35.06%) were Much Better. The mean treatment effect size (ES) was 1.87. Outcome varied significantly across diagnostic categories. Outcome also varied by age groups. Outcome for males and females did not differ, but both kinds of individual patients did better than when couples were the focus of treatment. The dropout rate was 17%. The mean number of sessions per case was 17.43, the median was 10, and the range was 1 to 344. There was a significant positive correlation between number of treatment sessions and outcome. The therapist's effectiveness did not improve across the years. Managed care had a significant negative impact on treatment outcomes.

Objective: In 2003, the U.S. Food and Drug Administration (FDA) issued a public health advisory about the risk of suicidality in pediatric patients taking selective serotonin reuptake inhibitors (SSRIs) for depression, and in 2005, the agency mandated a black box warning and medication guide indicating that pediatric and adult patients may be at risk. The authors examine the effects of this pediatric policy on treatment of adult depression in the community., Method: An adult cohort with newly diagnosed episodes of depression was created from a large national integrated claims database of managed care plans from October 1998 to September 2005 (N=475,838 unique episodes). Time-series analyses were used to compare the post-FDA advisory trends to the trends during the 5 years preceding the advisory., Results: The rate of diagnosed depression was significantly lower after the advisory than would have been expected on the basis of the preadvisory historical trend. The average percentage of adults with new (versus recurrent) depressive episodes was 88.6% in the preadvisory period (declining at an annual rate of 1.69%), and it decreased significantly to 77.5% (declining more rapidly, at an annual rate of 7.70%). The percentage of adults with depression who did not receive an antidepressant increased from an average of 20% (declining at 0.45% annually) before the policy action to an average of 30% (increasing at an annual rate of 20.6%). The data did not show any compensatory increases in psychotherapy or prescription of atypical antipsychotics or anxiolytics., Conclusions: The FDA advisory had a significant spillover effect into community treatment for adults with depression, despite the focus of the policy on pediatric patients.

Objective: In October 2003, the U.S. Food and Drug Administration (FDA) issued a public health advisory about the risk of suicidality in pediatric patients taking selective serotonin reuptake inhibitors (SSRIs) for depression. This study used data from a large national pediatric cohort to examine patterns of diagnosis of depression, prescription of antidepressants, prescription of pharmacological alternatives to antidepressants, and use of psychosocial care before and after the FDA advisory was issued., Method: A large pediatric cohort with newly diagnosed episodes of depression was created from a national integrated claims database of managed care plans from October 1998 to September 2005 (N=65,349). Time-series models were used to compare diagnosing and prescribing trends during the 2 years after the FDA advisory and the expected trends based on data from the 5-year period preceding the advisory., Results: From 1999 to 2004, pediatric diagnoses of depression increased from 3 to 5 per 1,000. After the FDA advisory was issued, the national rate decreased to 1999 levels, a significant deviation from the historical trend. Pediatricians and nonpediatrician primary care physicians accounted for the largest reductions in new diagnoses. Among patients with depression, the proportion receiving no antidepressant increased to three times the rate predicted by the preadvisory trend, and SSRI prescription fills were 58% lower than predicted by the trend. There was no evidence of a significant increase in use of treatment alternatives (psychotherapy, atypical antipsychotics, and anxiolytics)., Conclusions: The FDA advisory was associated with significant reductions in aggregate rates of diagnosis and treatment of pediatric depression.

Objectives: This study evaluated adherence with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) among patients who newly initiated therapy for anxiety with or without comorbid depression; the study also quantified the health-related economic consequences of nonadherence., Methods: A large managed care database was used to gather retrospective data for patients with anxiety disorders who had a prescription for an antidepressant between July 1, 2001, and December 31, 2002. The relationship between antidepressant adherence and medical resource utilization was assessed; the analysis controlled for age, gender, utilization of mental health specialty care, change in medication, whether the dosage was titrated, costs in the six months before the prescription for an antidepressant, and comorbid physical conditions., Results: Of the 13,085 patients with anxiety diagnoses who met the criteria for study inclusion, 57 percent were nonadherent to antidepressant therapy at six months. Patients who received mental health specialty care were more likely than those who did not receive such care to be adherent to therapy (48.5 percent compared with 40.7 percent; p<.001). Those with dual diagnoses of anxiety and depression were more likely than those with anxiety alone to be adherent to therapy (46.8 percent compared with 40.2 percent; p<.001). Those with a coded diagnosis of posttraumatic stress disorder had the highest medical costs. Patients with anxiety and depression had significantly higher total costs than patients with anxiety alone. Adherent patients who did not have a change in medication or a titrated dosage had significantly lower medical costs than nonadherent patients; however, total costs (medical plus pharmacy) were similar., Conclusions: Nonadherence with antidepressant therapy in anxiety disorders is common, but mental health specialty care may be associated with improved adherence. Lower medical costs for adherent patients who did not have a change in medication or a titrated dosage offset the increase in pharmacy costs, resulting in total costs (medical plus pharmacy) that were similar to those of nonadherent patients.

Objective: This study examined whether implementation of managed care in a public mental health system affected return visits to psychiatric emergency services within 180 days of an index visit., Methods: Data were taken from an administrative database of 75,815 patient visits made to a hospital-based psychiatric emergency service for mental health care between January 1, 1995, and December 31, 2002. Rates of return visits for patients whose index visit occurred at least 26 weeks before a system of managed care was implemented in 1999 were compared with rates for patients whose index visit occurred after the implementation but at least 26 weeks before the data collection period ended. Declining-effects modeling was used to adjust for patients' gender, ethnicity, age, and admission status., Results: A total of 37,371 patients met study criteria for inclusion: 21,135 before managed care was implemented and 16,236 after managed care was implemented. In the pre-managed care group, 3,687 patients (17 percent) made a repeat visit within 26 weeks of their index visit; 2,369 patients (15 percent) in the post-managed care group made such a repeat visit. For any given index visit to the psychiatric emergency department, patients who presented for treatment after managed care were only 90 percent as likely as patients who presented before managed care to have a return visit within the first five weeks after the index visit. However, there was essentially no difference between groups in the likelihood of a return visit by week 26 after the index visit, suggesting that managed care delayed, but did not eliminate, return visits. In addition, the number of police-accompanied index visits continued to rise after managed care was implemented (from 32.0 to 52.6 percent of all index visits), suggesting that increasing numbers of patients with mental illness in need of treatment were coming to the attention of law enforcement officials after managed care was implemented., Conclusions: Managed care strategies are often used to reduce reliance on emergency services. In this study, managed care delayed, rather than prevented, return visits to the psychiatric emergency service.

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.

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.

Objectives: This study was a first step in explicitly attempting to open, at least partially, the "black box" of specialty managed mental health care by examining qualitative as well as quantitative aspects of managed outpatient mental health treatment. The Goal Focus Treatment Planning and Outcomes (GFTPO) program was studied as an example of a relatively simple, patient-specific, structured educational intervention with a modest capacity to affect practice patterns and care over time among network clinicians., Methods: Four years of data from an enhanced care management program (N=28,741) designed to facilitate focused, goal-oriented, accountable outpatient psychotherapy and appropriate use of medications were used to illustrate what was actually done in one large national managed behavioral health organization. Random samples of persons from seven matched pairs of GFTPO (N=17,752) and non-GFTPO (N=10,989) employer groups from 1995 to 1998 were studied in a quasi-experimental design. The effects of GFTPO were tested by analyzing samples compared on five measures of outpatient psychotherapy: errors in prescribing medication, continuity of therapists, early termination of treatment, likelihood of multiple treatment episodes, and the use and cost of services., Results: The GFTPO sample showed a lower incidence of medication prescribing errors and therapist switching as well as shorter treatment episodes in the year after the start of outpatient treatment. No differences were observed in the likelihood of early termination or of having multiple treatment episodes. Cost savings did not appear to be at the expense of quality of care., Conclusions: It is possible to enhance the potential for measuring and influencing the quality of care in large organized systems.

Objectives: The authors studied enrollees in employer-sponsored managed health plans to determine the extent of multiple behavioral health consumers within families, use of behavioral health services by employees who have another family member using such services, congruence of diagnoses between two family members using behavioral health services, and the effect on covered charge per behavioral health consumer when other family members use behavioral health services., Methods: Claims data from 911 plans sold or managed by a single managed behavioral health care company were examined. The plans provided coverage for 724,789 employees and covered about 1.7 million lives. Family members of employees were identified by the relationship codes on the claims. Service utilization rates were calculated for employees overall and for employees who had spouses or children who used behavioral health services. Mean and median covered charges were determined and were examined by number and type of consumers in the family., Results: The use of behavioral health services was greater among employees whose children or spouses used behavioral health services. Utilization rates varied by the child's or spouse's diagnoses. More than 50 percent of male employees whose children received treatment for a depressive disorder also received such treatment. Congruence of diagnoses within families was noted. Covered charges per person generally increased with the number of family members who used behavioral health services., Conclusion: Greater knowledge about patterns of use of behavioral health services within families may help in improving access to care and developing more effective family interventions.

In response to the effects of the managed care environment on patient flow and care, the department of psychiatry and behavioral sciences of the Johns Hopkins School of Medicine developed and has been managing a capitated behavioral health care program. The program is responsible for providing mental health and substance abuse services for 22,000 members of the TRICARE Uniformed Services Family Health Plan (USFHP), directed by the U.S. Department of Defense. The integration of primary care and behavioral health care is a major feature of the USFHP/TRICARE program. The authors describe the transition from a carve-out for-profit managed care organization to the integrated program managed by the department. During the first two years of the program, access to services increased and use of inpatient services decreased without the need to deny service use. To supplement previous reports of the involvement of academic psychiatry departments in behavioral health care, the authors supply utilization and financial data that may serve as benchmarks for similar efforts by other departments.

Objective: The authors determined the costs associated with generalized social anxiety disorder in a managed care setting., Method: A three-phase mail and telephone survey was conducted from July to October 1998 in two outpatient clinics of a large health maintenance organization (HMO). The survey assessed direct costs, indirect costs, health-related quality of life, and clinical severity associated with generalized social anxiety disorder, both alone and with comorbid psychopathology., Results: The weighted prevalence rate of current generalized social anxiety disorder was 8.2%. In the past year, only 0.5% of subjects with generalized social anxiety disorder had been accurately diagnosed. Yet 44.1% had a mental health specialty visit or had been prescribed an antidepressant, and psychiatric comorbidity was found in 43.6%. Noncomorbid generalized social anxiety disorder was associated with significantly lower health-related quality of life, work productivity, and earnings and greater utilization of health services; generalized social anxiety disorder with comorbid psychopathology was even more disabling. Suicide was attempted by 21.9% of subjects with noncomorbid generalized social anxiety disorder. Persons with average-severity generalized social anxiety disorder had probabilities of graduating from college that were 10 percentage points lower, earned wages that were 10% lower, and had probabilities of holding a technical, professional, or managerial job that were 14 percentage points lower than the comparison group., Conclusions: In a community cohort of HMO members, generalized social anxiety disorder was rarely diagnosed or treated despite being highly prevalent and associated with significant direct and indirect costs, comorbid depression, and impairment.

Objective: This study examined the sociodemographic and clinical characteristics of acute-care psychiatric patients who visited the emergency department at a large public hospital in terms of the patients' enrollment status in the region's public managed mental health care plan. The results of the analyses were expected to provide information about the degree and types of access to care for individuals who are and are not enrolled in the plan., Methods: Data were collected over a seven-month period for 2,419 patients who visited a large, inner-city crisis triage unit. Patients were grouped according to whether they were currently enrolled, previously enrolled, or never enrolled in the public managed mental health care plan. Univariate and logistic regression models were used to determine differences between the three groups., Results: In general, patients who were currently enrolled in the plan had a higher rate of functional psychosis, past use of psychiatric services, and functional disability and lower rates of substance use and homelessness. Previously enrolled patients had a more moderate rate of psychosis but a higher rate of substance use, functional disability, and homelessness. The never-enrolled patients had a lower rate of psychosis, functional disability, and past use of psychiatric services, and moderate substance use., Conclusions: The region's public health plan appeared to be succeeding in engaging and keeping the most psychiatrically impaired patients in treatment; however, individuals with moderate psychiatric symptoms and high levels of substance abuse may never have been enrolled in the plan because of Medicaid ineligibility or because they dropped out of treatment. Problematic behavior and history of hospitalization were the best predictors of enrollment status.

Objective: Data from a survey of managed behavioral health care organizations were analyzed to describe characteristics of these firms as well as service utilization and revenues., Methods: Six managed behavioral health care organizations fully completed a survey by the American Managed Behavioral Healthcare Association in which they reported 1996 data for their contracts. The contracts represented more than 16 million covered lives and accounted for approximately 13 percent of all individuals enrolled in managed behavioral health care organizations in 1996., Results: More than three-quarters of the contracts (77.5 percent) were nonrisk. Plans described as network-based risk contracts, which represented 28.7 percent of covered members, accounted for 71.1 percent of revenues. The vast majority of reported contracts were with private employers or health maintenance organizations (HMOs); these contracts accounted for 76.8 percent of reported revenues. HMOs tended to place somewhat greater restrictions on outpatient psychotherapy and outpatient medication management visits than did other types of payers; the most common limit for HMO-related contracts was 20 outpatient visits a year, compared with 50 visits a year for other payer categories. HMO contracts also required higher copayments for outpatient visits. Utilization of services differed by payer type; for example, use of inpatient services ranged from.18 percent of covered members for contracts with private employers to.90 percent of covered members for Medicaid contracts., Conclusions: Overall rates of service utilization were lower than those reported in other recent studies of managed behavioral health care. The survey findings provide a starting point to guide further investigation in this area.

Objective: The utilization management process of a managed behavioral health organization was examined to determine the frequency and types of reviews and the extent to which rationing of service was achieved through the denial of services., Methods: A case study of the utilization management program of a large managed behavioral health organization was done. Information was gathered from claims for 1997, and utilization review data were drawn from 51 plans. Data were examined by review type and authorization actions., Results: The utilization management program performed a total of 9, 639 reviews. The most common type was concurrent review for additional outpatient therapy visits (46 percent). The second most common type was concurrent facility review (12.9 percent). The vast majority of authorizations were approved at the level requested by the provider (91.8 percent). Very few services were denied (.8 percent) or approved at a level lower than requested by the provider (1.3 percent)., Conclusions: Although concerns have been raised about the high denial rates of utilization management programs, this study found very low denial rates. Further studies are needed to determine the precise mechanisms used in utilization management programs to control utilization. In addition, the large number of reviews raises questions about the time and opportunity costs of the review process.

Objective: The study examined the rate and duration of outpatient substance abuse treatment following inpatient detoxification under managed care., Methods: Seven years of claims data from a large behavioral health care carve-out plan were used to identify patients. Rates and duration of formal substance abuse treatment following detoxification were calculated, and regression models were used to explore factors that may affect participation in treatment., Results: Seventy-nine percent of the detoxification patients received formal substance abuse treatment, the majority within the week following discharge. Formal follow-up care lasted an average of ten weeks, with visits occurring on average about once a week. When other variables likely to influence participation in substance abuse treatment were controlled for, the level of outpatient copayments significantly affected the rate of participation in treatment., Conclusions: These findings indicate that the rate of participation in outpatient treatment after detoxification is high, but room for improvement remains. The results suggest that reducing copayment levels is one mechanism for increasing the likelihood that individuals with severe drug and alcohol problems will receive subsequent treatment. The need for such treatment is underscored by the severity of illness of those who undergo detoxification and the societal costs of untreated substance use disorders.

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.

Objective: A central assumption underlying managed care is that plan switching is a viable option for enrollees when they are dissatisfied. The authors used a national employee survey to test the hypothesis that this mechanism is less effective for enrollees with high levels of depressive symptoms than for the remainder of the population., Method: The study used data from the Employee Health Care Value Survey, a 1993 survey of 20,283 employees of three major corporations. The authors used the Medical Outcomes Study 36-Item Short-Form Health Survey to identify individuals with the highest decile of depressive and physical symptoms. They examined the relationship between symptoms and dissatisfaction and, for dissatisfied individuals, how symptoms predicted plan switching. Multivariate models were used to control for potential demographic, health, and health coverage confounders., Results: Depressive and physical symptoms were both associated with dissatisfaction with care. Unlike physical symptoms, depressive symptoms were associated with a significantly lower likelihood of actually disenrolling among people who were dissatisfied or who intended to disenroll. This effect was most pronounced for satisfaction with administrative aspects of care (e.g., gatekeeping, utilization review)., Conclusions: People with high levels of depressive symptoms appeared to be less willing or able to act on their dissatisfaction by switching plans. In particular, they were willing to tolerate higher rates of dissatisfaction with the administrative aspects of their health coverage without disenrolling. Plan switching is an essential mechanism underpinning a health care system predicated on competition; it may be less effective for people with depressive disorders.

Objective: Outpatient claims data from a managed behavioral health company for 1996 were examined to determine the extent to which patients received services from different types of mental health care providers., Methods: Claims data for 1996 were obtained from 75 plans with more than 600,000 members that were managed by one behavioral health care organization. Data were examined by type of provider and diagnosis., Results: A total of 349,686 claims were examined. Doctoral-level psychologists accounted for most claims (33.4 percent), followed by psychiatrists (30.5 percent), social workers (19.8 percent), and other master's-level therapists (13.8 percent). Ninety-five percent of patients with a psychotic disorder and 86.2 percent of individuals with bipolar disorder were seen either by a psychiatrist alone or by a psychiatrist in combination with another provider. Among depressed patients, 62.9 percent were seen by a psychiatrist, alone or in combination with another provider. Only 23 percent of patients with an adjustment disorder and 14.1 percent of those with a V-code diagnosis were treated by a psychiatrist, alone or in combination with another provider. Because psychiatrists treated sicker patients, their proportion of patients treated (24.7 percent) was smaller than their proportion of all claims filed. Most patients (78.9 percent) saw only one type of provider., Conclusions: The results allay concerns that managed care shifts patients away from psychiatrists to doctoral-level psychologists and less expensive providers. The majority of patients with depressive disorders and almost all patients with psychotic disorders had contact with a psychiatrist.

Managed care in the public sector remains a poorly defined concept. It is currently understood largely through case examples, an approach of limited usefulness because each managed care initiative is shaped by local forces and is constantly changing. The authors describe ten key dimensions on which such initiatives vary and suggest that they can be used to examine essential characteristics of the initiatives and core differences between them. The dimensions are objectives, scope, organizational structures and authority, enrollment, benefit package, strategies for managing utilization, best practices, financing, quality management and outcomes measurement, and the impact of the initiative on the public mental health system. Using these dimensions to assess existing initiatives, the authors conclude that most focus on one principal dimension to the exclusion of other critical dimensions. The authors argue for a comprehensive approach to planning and implementing managed care projects that should ultimately lead to better care for public-sector populations.

Objective: Cost and utilization patterns of substance abuse and mental health treatment under private, employer-sponsored, managed behavioral health care plans were examined., Methods: Data were from claims made in 1995 in 93 behavioral health care plans covering 617,133 members. Rates of use of mental health and substance abuse care were determined, as were payments by insurers and patients for the two types of care. Means were calculated per plan member and per user of either of these service types., Results: Approximately .3 percent of plan members used any substance abuse services; 5.2 percent used mental health services. However, among substance abuse patients, average costs were more than twice as high as average costs for mental health patients. For substance abuse treatment, the annual cost per user was $2,188, compared with $979 for users of mental health care. Annual per-member costs were $6.51 for substance abuse treatment and $50.08 for mental health care. Higher costs for substance abuse treatment reflected greater rates of use of both inpatient and intensive outpatient treatment. Overall, substance abuse costs represented 13 percent of insurance payments for behavioral health care and perhaps .4 percent of the cost of health insurance overall., Conclusions: Substance abuse coverage accounts for a small fraction of insurance payments for behavioral health coverage and a very small fraction of insurance payments for both physical and behavioral health care.

Objective: Service costs and utilization patterns of children in carved-out behavioral health care plans were examined and compared with those of adults., Methods: Twelve-month data on utilization and costs of behavioral health care from one managed behavioral health care carve-out organization, United Behavioral Health, were examined for three age groups of children--birth to five years, six to 12 years, and 13 to 17 years-and for adults. More than 600,000 enrollees in 108 different plans were included in the data. Rates of use and intensity of use were examined separately by type of service-inpatient, outpatient, and partial hospitalization., Results: Only a small number of all enrollees used any behavioral health care services--4.2 percent used outpatient services, .3 percent used inpatient services, and .2 percent used partial hospitalization services. Adolescents were more than twice as likely as adults and about seven times as likely as children aged 6 to 12 to use inpatient services. Adolescents also had a slightly higher probability of using outpatient care than adults, while younger children had lower rates of outpatient use than adolescents or adults. Adolescents were also more likely than adults and other children to have very high costs of inpatient care (mean costs=$8,975 for adolescents and $4,750 for adults). Adults were more likely than other groups to have higher outpatient costs ($640 for adults and $513 for all children)., Conclusions: The finding that children, and adolescents in particular, are more likely to have very high inpatient costs compared with adults implies that they may benefit most from the elimination of caps on mental health care costs covered by insurance. This profile of children's behavioral health care utilization patterns can be useful to policy makers in considering expansions in children's health insurance coverage.

Objective: This exploratory study examined utilization and costs among depressed patients in two treatment models-integrated treatment, in which psychotherapy and pharmacotherapy were provided by a psychiatrist, and split treatment, in which pharmacotherapy was provided by a psychiatrist and psychotherapy by a nonphysician psychotherapist., Methods: A quasi-experimental retrospective design was used to compare claims data from a national managed mental health care organization for 191 patients in integrated treatment and 1,326 in split treatment., Results: During the 18-month study, patients receiving integrated treatment used significantly fewer outpatient sessions and had significantly lower treatment costs, on average, than those in split treatment. Integrated treatment appeared to be associated with a pattern of utilization characterized by frequent treatment episodes in contrast to that of split treatment, which was characterized by more sessions with fewer breaks of 90 days or more., Conclusions: The results do not support the prevailing assumption that integrated treatment is more costly than split treatment in a managed care network. Despite limitations in the study methods, the strength of these preliminary findings poses a powerful challenge and invites further study.

Objective: The study examined the characteristics of frequent users of inpatient treatment under public-sector managed care in Massachusetts between 1992 and 1995 and explored whether their pattern of inpatient utilization affected their overall use of hospital days., Methods: Individuals with five or more admissions in any of four fiscal years (1992 to 1995) were identified using the Massachusetts Department of Mental Health client tracking system. The demographic and clinical characteristics of these patients and the types of hospitals they used were compared with those of all patients in case management programs who had a hospital admission but who did not meet study criteria for multiple admissions., Results: Compared with other patients, patients with multiple admissions were more likely to be young Caucasian females with personality disorder and a history of substance abuse but not a current substance use disorder. They tended to be lower functioning as measured by the Georgia Role Functioning Scale (GRFS) and to have higher levels of distress, as measured by the global personal distress portion of the GRFS. They made up 6 to 8 percent of all clients with a psychiatric admission who were enrolled in a case management program, but they accounted for 21 to 27 percent of all admissions in the four fiscal years. Patients with multiple admissions had significantly longer lengths of stay when admitted to a hospital where they had not been previously admitted in the past 12 months., Conclusions: States setting up public-sector managed care or revising existing public-sector managed care contracts should ensure that subpopulations of persons at high risk for multiple admissions receive special attention. They should also create networks of inpatient providers to enable frequent users of acute care facilities to return to the same facility that previously discharged them.

Objective: The authors' goal was to characterize psychiatric practice by reporting findings from the 1996 National Survey of Psychiatric Practice., Methods: A random sample of 1,481 APA members was selected to participate in the study; 1,375 APA members were determined to be eligible for study participation. The authors report data from 970 respondents (70.5% response rate) and compare them with data from previous surveys of psychiatrists., Results: Twenty-five percent of the participating psychiatrists were women, compared with 19% in a 1988-1989 survey. Since 1988-1989, the proportion of psychiatrists 39 years old or younger has decreased and the proportion of those 55 years old or older has increased. In 1996, psychiatrists saw, on average, 35.4 unduplicated patients and worked an average of 46.4 hours in a typical week. Patients with mood disorders as their primary diagnoses accounted for the greatest proportion of psychiatrists' caseloads, followed by patients with anxiety disorders, then those with schizophrenia and other psychotic disorders. Public sources of payment and uncompensated care were the main sources of payment for psychiatrists services for 41.7% of patients. The primary payment mechanism for psychiatrists' patient care services was fee-for-service, accounting for 52.5% of psychiatrists' income from direct patient care. Twenty-nine percent of psychiatric patients received care through some form of managed care system, and 41.6% received treatment through a nonmanaged public or private health plan., Conclusions: As psychiatry moves into the next century, findings from the National Survey of Psychiatric Practice will form a baseline for monitoring changes and trends in the delivery and financing of mental health services.

Intensive case management for severely psychiatrically ill patients is a relatively new phenomenon in the private sector. The authors describe a comprehensive case management program designed at Blue Cross Blue Shield of Massachusetts to meet the needs of the most severely ill psychiatric patients in a private managed care environment. The case management program emphasizes involvement of patients in creating comprehensive treatment plans; development of a relationship between case managers, patients and their families, and providers; and clinical coordination between the public and private sectors to create individualized treatment plans. The program's case managers are able to flex the benefit limitations of a managed care or indemnity plan to integrate public and private services and can enlist providers outside a managed care network. The paper describes service utilization by the first 33 patients who participated in the program for one year.

Managed care programs establish procedures to help their patients avoid use of psychiatric emergency services. To determine whether managed care patients who do visit the emergency service do so primarily for hospitalization and have briefer contacts with the service because of preapproval for hospitalization, records were examined for 293 patients who visited a psychiatric emergency service; 69 were enrolled in a managed care plan. The findings did not confirm the expectations: many managed care patients received crisis services and were referred for outpatient care. The non-managed-care group had more psychotic and substance use disorders, required more emergency community intervention, and had more previous psychiatric hospitalizations.