Does PsychiatricCare by Family Practitioners Reduce the Cost of General Medical Care? Alex Richman M.D., M.P.H.
This is the first “impact” type of economic study of psychiatric/counseling services from general practitioners. The paper analyzes a province-wide database that collates statistical data from all inpatient and outpatient psychiatric services as well asfrom private physicians. This paper asks whether psychiatric services from family physicians also reduce the overall costs of medical care. This research supports the general research findings that medical costs are lower after psychiatrists’ care. ECT patients show a marked reduction in their medical costs. Patients with psychotherapy/counseling from family physicians did not show statistically significant reductions in overall medical costs. We need new classifications for the kinds of mental disorders seen in primary care settings. Abstract:
Introduction Recent research has studied the “impact” of psychiatrists’ care on the costs of medical care. Persons with mental disorders usually have above-average medical costs. Jones and Vischi [l] reviewed 25 studies of the impact of treatment of mental disorders on medical costs. Brief individual psychotherapy resulted in fewer days of hospitalization for patients on medical or surgical services of a general hospital; in clinics or HMOs brief psychotherapy decreased the number of visits to primary health care providers, and reduced overall direct health care costs [2]. Retrospective analyses of 58 controlled studies converged to provide evidence of a general cost-offset effect following outpatient psychotherapy [3]. A prospective study of liaison From the Departments of Psychiatry and Community Health and Epidemiology, Clinical Research Center, Dalhousie University, Halifax, Nova Scotia, Canada. Address correspondence to: Alex Richman, M.D., M.P.H., Psychiatry, Com&mity Health 6r Epidemiology, Cl&Cal Re: search Center, Dalhousie University, 5t349 University Avenue, Halifax, Nova Scotia B3H 4H7, Canada. General Hospitd Psychiatry 12, 19-22, 1990 0 1990 Elsevier Science Publishing Co., Inc.
655AvenueoftheAmericas,NewYork,NYlOOlO
psychiatry showed a favorable influence on clinical outcome and reduced costs of medical care [4]. Detectable mental disorders are common in the community and are often untreated. Psychiatrically ill patients who seek treatment are seen less often by mental health specialists than by primary care physicians who appear to respond to such distress more often than they diagnose it [5]. Short training programs can help family physicians significantly increase their ability to detect emotional problems [6]. Support, advice, and reassurance from family physicians is routine in many family practices; however, there is a dearth of reliable information about the impact of such practices [7]. Few investigators compare the therapeutic practices of primary care physicians and mental health clinicians [8]. This paper asks whether psychiatric services from family physicians also reduce the overall costs of medical care.
Psychiatric Care by Family Physicians in Canada The Canadian National Health Insurance program is universal; it is available to all Canadian residents on equal terms and conditions. The program provides hospital and medical (private office) care. Canadian Medicare has no restrictions on the amount or duration of psychiatric care. Patients do not pay co-insurance fees and there is no extrabilling from physicians. Patients may choose their physician. The fee-for-service system pays family physicians for counseling and psychiatric services [9]. Family physicians now receive 40% of the total Medicare payments for psychotherapy and counseling. Psychotherapy and counseling now account for 7% of the family physician’s total income from office visits. The recognition of mental disorders 19
ISSN 0163-8343&l/$3.50
A. Richman
and emotional reactions is substantial. In some provinces family physicians provide psychiatric/ counseling services to 12% of young women in urban areas and to 7% in rural areas [lo].
Methods Development of Data Base This study is based on the experience of one province, New Brunswick, with a population of 700,000. The province-wide statistical files for all psychiatric services were collated. The first collation included psychiatric contacts with mental hospitals, general hospitals (both psychiatric units and scatter beds), outpatient clinics, and private practitioners (both psychiatrists and general practitioners). The second step added the nonpsychiatric contacts (in general hospitals and with private physicians) to the data base. The final data base included statistical data for over 90,000 individuals over the 7-year period 1975-1981. Since Medicare is universal, there is no bias in the selection of patients or practitioners. The file has no information that identifies individuals.
Table 1. Costs of medical care before and after first psychiatric contact Family physician Psychiatrist Number of cases Medical costs in year (01) before first
psychiatriccontact Medicalcosts in year (02) after first psychiatric contact Medical costs in second year (03) after first psychiatric contact f-test years 01,02 p (two tailed) t-test years 01,03 p (two tailed)
ECT
160
32
30
$ 83
$188
$126
$132
$138
$ 41
$ 93 3.51 CO.01 0.25 0.25
$ 97 - 1.27 0.21 -1.18 0.24
$ 31 -1.95 0.06 -2.28 0.03
Note: Medical costs also include costs of psychiatric services.
ambulatory, and hospital) for three time periods related to the first psychiatric contact: Time 01: the 12 months before the first contact, Time 02: the 12 months after the first contact, and
Selechon of Subsample
Time 03: the 13th-24th month after the first contact.
Since the original file is too large to analyze on a microcomputer, initial analyses are based on a randomly selected 1% sample. In order to have at least one full year of observation before initial psychiatric contact and at least two years after, a 4-year observation “window” was selected for cases first seen during 1976-1979. Because of the relatively small proportion of male patients seen in private practices, we restricted the sample to women aged 15-64. There are no diagnostic data for ambulatory services from private physicians. The final step was to exclude persons with mixed contacts. The cases were divided into three clinical subgroups: fumiZyphysician patients had at least one psychotherapy/counseling service and contact with no other ambulatory or inpatient service; psychiutrist patients had at least one office contact with a private psychiatrist and contact with no other ambulatory or inpatient service; and ECT patients had at least one electroconvulsive treatment. This group may also have had ambulatory services from private psychiatrists or general practitioners. The annual costs were compared of all private medical services (family physician and specialists,
A paired t-test was used to assess the statistical significance of any difference in the total costs before and after the onset of psychiatric care.
Results The psychiatrist and the ECT groups had lower medical costs in the years following first psychiatric contact. The reductions for the psychiatrist group were not statistically significant. The ECT group reductions were far greater than for the psychiatrist group and were statistically significant (t-test = 2.28, p = 0.03) The family physician group had higher medical costs following the start of initial psychotherapy/ counseling. Year 03 costs were less than year 02 but still higher than during year 01. The differences (despite a far larger n in this group) were not statistically significant.
Discussion This is the first “impact” type of study of psychiatric services from family physicians. There
Psychiatric Care by Family Practitioners
are three important factors that might account for the apparent lack of impact of family physician counseling/psychotherapy on medical costs. First, in this study the disorders recognized by the family physicians may have been at a very early stage and therefore of mild severity or of short-limited duration. It is not possible to distinguish the type or severity of disorders in this database nor is it possible to differentiate the therapeutic approach. Recognition and intervention may have occurred so early that there was little opportunity for markedly increased medical costs. The data support this possibility. The pretreatment costs were far less for the family physician group than for the psychiatrist or ECT treated groups. Future impact studies must specify the stage of the disorder, define its severity, and differentiate transient from more durable disorders. Second, in this study patients saw their own family physician. In contrast, in the usual impact study mental health specialists see the patients. Consultation with an outside specialist may be the crucial factor in reducing the use of general health services. The usual consultation with a mental health specialist involves two factors [ll]: 1) the specialist showing an active interest in the patient; and 2) the patient having the opportunity to tell his or her story in a leisurely, unhurried manner. In addition, the consultant may provide a different perspective. The consultation could promote better understanding of the nature of the patient’s symptoms, invoke alternative support systems or start more appropriate treatment. It is worthwhile assessing the consultant factor further in non-mental disorders. Is there a reduction of general medical costs after consultation with nonsurgical consultants such as gastroenterologists, dermatologists, and rheumatologists? Third, there is the additional problem of procedural terminology. The study groups were defined in somewhat different ways, the ECT patients by specific, homogeneous procedure; the psychiatrist patients by contact with a specialist; the family physician group by a less specific procedural item-counseling or medical psychotherapy. It is possible that some of these patients received additional counseling for a physical disorder rather than for a mental disorder. Future studies should determine whether the visit and treatment were primarily for a mental disorder or for further counseling about a physical disorder.
Ideally we need appropriate randomized clinical trials to assess the impact of psychiatric care. However, we can still gain better understanding of the dynamics of family physician interventions from quasi-experimental studies of administrative data bases. Later analyses of this database can include a larger sample, include males and analyze age differentials. They should consider changes in hospital use and the actual amount and duration of psychotherapy/counseling from family physicians. Future research should consider the clinical disorders and office procedures preceding the psychiatric care. Recent reports have emphasized the problems of recognition and therapy of depression in specialist settings. Keller [12] concluded that most individuals did not receive pharmacotherapy long enough or at a sufficiently high dose to produce a therapeutic response. Later, Kupfer and Freedman [13] discussed the need to consider the particulars of specialist treatment, to assess the attitudes of therapists, and to describe the circumstances of treatment decisions. Before we can develop these “circumstance-of-therapy” studies for primary care we need better instruments. Mental disorders seen in primary care do not conform to the classifications and therapeutic approaches provided in specialist settings [ 141. We need new instruments and classifications for primary care settings. With these new instruments we can then begin to determine the relative ability of psychiatrists and family physicians to identify and treat the types of problems commonly seen in general practice.
Conclusions 1. This research supports the general research findings that medical costs are lower after psychiatrists’ care. 2. ECT patients show a marked reduction in their medical costs. 3. Patients with psychotherapy/counseling from family physicians did not show a reduction in overall medical costs. 4. Future studies should include larger samples, consider changes in the pattern of hospital use, determine the actual amount and duration of psychotherapy/counseling from family physicians, and analyze the clinical disorders and office procedures preceding the psychiatric care. 21
A. Richman
References 1. Jones K, Vischi T: Impact of alcohol, drug abuse and
2. 3.
4. 5. 6.
7.
22
mental health treatment on medical care utilization. Med Care 17(Suppl):l-81, 1979 Ursano RJ, Hales RE: A review of brief individual psychotherapies. Am J Psychiatry 143:1507-1517, 1986 Mumford E, Schlesinger HJ, Glass GV, Patrick C, Cuerdon T: A new look at evidence about reduced cost of medical utilization following mental health treatment. Am J Psychiatry 141:1145-1158, 1984 Levitan SJ, Kornfeld DS: Clinical and cost benefits of liaison psychiatry. Am J Psychiatry 138:790-793, 1981 Glass RM, Freedman DX: Psychiatry. JAMA 254: 2281-2283, 1985 Gask L, McGrath G, Goldberg D, Millar T: Improving the psychiatric skills of the experienced family doctor: An evaluation of a group training course. In Mental Disorders in General Health Care Settings: A Research Conference. Battelle Conference Center, Seattle Washington, June 25-26, 1987, Bethesda, MD, NIMH, 1987, pp. 209-211 Clare AQ, Williams I?: A personal view. In Williams P, Clare AW (eds), Psychosocial Disorders in General Practice, London, Academic Press, 1975, pp. 325-332
8. Wilkinson G: Overview of Mental Health Practices in Primary Care Settings, with Recommendations for Further Research. Mental Health Service System Reports DN No. 7. RockviIle, MD, NIMH, 1986 9. Richman A, Brown MG: Reimbursement by medicare for mental health services by general practitioners-Clinical, epidemiologic and cost containment implications of the Canadian experience. In Parron DL, Solomon F (eds), Mental Health Services in Primary Care Settings, Report of a Conference April 23,1979, Washington, DC, NIMH, Mental Health Service System Reports, 1980, pp. 122-130 10. Richman A: Psychiatry. In The Canadian Encyclopedia, 2nd ed. Calgary: Hurtig Publishers, 1988, pp. 1776-1778 11. Shorter E: Bedside Manners: The Troubled History of Doctors and Patients. New York, Simon and Schuster, 1985 12. Keller MB, et al: Treatment received by depressed patients. JAMA 248:1848-1855, 1982 13. Kupfer DJ, Freedman DX: Treatment for depression: ‘Standard’ clinical practice as an unexamined topic. Arch Gen Psychiatry 43:509-511, 1986 14. Barrett J: Case identification for category validation: The challenge of disorder-specific assessment. Compr Psychiatry 27:81-100, 1986
This is the first “impact” type of economic study of psychiatric/counseling services from general practitioners. The paper analyzes a province-wide database that collates statistical data from all inpatient and outpatient psychiatric services as well asfrom private physicians. This paper asks whether psychiatric services from family physicians also reduce the overall costs of medical care. This research supports the general research findings that medical costs are lower after psychiatrists’ care. ECT patients show a marked reduction in their medical costs. Patients with psychotherapy/counseling from family physicians did not show statistically significant reductions in overall medical costs. We need new classifications for the kinds of mental disorders seen in primary care settings. Abstract:
Introduction Recent research has studied the “impact” of psychiatrists’ care on the costs of medical care. Persons with mental disorders usually have above-average medical costs. Jones and Vischi [l] reviewed 25 studies of the impact of treatment of mental disorders on medical costs. Brief individual psychotherapy resulted in fewer days of hospitalization for patients on medical or surgical services of a general hospital; in clinics or HMOs brief psychotherapy decreased the number of visits to primary health care providers, and reduced overall direct health care costs [2]. Retrospective analyses of 58 controlled studies converged to provide evidence of a general cost-offset effect following outpatient psychotherapy [3]. A prospective study of liaison From the Departments of Psychiatry and Community Health and Epidemiology, Clinical Research Center, Dalhousie University, Halifax, Nova Scotia, Canada. Address correspondence to: Alex Richman, M.D., M.P.H., Psychiatry, Com&mity Health 6r Epidemiology, Cl&Cal Re: search Center, Dalhousie University, 5t349 University Avenue, Halifax, Nova Scotia B3H 4H7, Canada. General Hospitd Psychiatry 12, 19-22, 1990 0 1990 Elsevier Science Publishing Co., Inc.
655AvenueoftheAmericas,NewYork,NYlOOlO
psychiatry showed a favorable influence on clinical outcome and reduced costs of medical care [4]. Detectable mental disorders are common in the community and are often untreated. Psychiatrically ill patients who seek treatment are seen less often by mental health specialists than by primary care physicians who appear to respond to such distress more often than they diagnose it [5]. Short training programs can help family physicians significantly increase their ability to detect emotional problems [6]. Support, advice, and reassurance from family physicians is routine in many family practices; however, there is a dearth of reliable information about the impact of such practices [7]. Few investigators compare the therapeutic practices of primary care physicians and mental health clinicians [8]. This paper asks whether psychiatric services from family physicians also reduce the overall costs of medical care.
Psychiatric Care by Family Physicians in Canada The Canadian National Health Insurance program is universal; it is available to all Canadian residents on equal terms and conditions. The program provides hospital and medical (private office) care. Canadian Medicare has no restrictions on the amount or duration of psychiatric care. Patients do not pay co-insurance fees and there is no extrabilling from physicians. Patients may choose their physician. The fee-for-service system pays family physicians for counseling and psychiatric services [9]. Family physicians now receive 40% of the total Medicare payments for psychotherapy and counseling. Psychotherapy and counseling now account for 7% of the family physician’s total income from office visits. The recognition of mental disorders 19
ISSN 0163-8343&l/$3.50
A. Richman
and emotional reactions is substantial. In some provinces family physicians provide psychiatric/ counseling services to 12% of young women in urban areas and to 7% in rural areas [lo].
Methods Development of Data Base This study is based on the experience of one province, New Brunswick, with a population of 700,000. The province-wide statistical files for all psychiatric services were collated. The first collation included psychiatric contacts with mental hospitals, general hospitals (both psychiatric units and scatter beds), outpatient clinics, and private practitioners (both psychiatrists and general practitioners). The second step added the nonpsychiatric contacts (in general hospitals and with private physicians) to the data base. The final data base included statistical data for over 90,000 individuals over the 7-year period 1975-1981. Since Medicare is universal, there is no bias in the selection of patients or practitioners. The file has no information that identifies individuals.
Table 1. Costs of medical care before and after first psychiatric contact Family physician Psychiatrist Number of cases Medical costs in year (01) before first
psychiatriccontact Medicalcosts in year (02) after first psychiatric contact Medical costs in second year (03) after first psychiatric contact f-test years 01,02 p (two tailed) t-test years 01,03 p (two tailed)
ECT
160
32
30
$ 83
$188
$126
$132
$138
$ 41
$ 93 3.51 CO.01 0.25 0.25
$ 97 - 1.27 0.21 -1.18 0.24
$ 31 -1.95 0.06 -2.28 0.03
Note: Medical costs also include costs of psychiatric services.
ambulatory, and hospital) for three time periods related to the first psychiatric contact: Time 01: the 12 months before the first contact, Time 02: the 12 months after the first contact, and
Selechon of Subsample
Time 03: the 13th-24th month after the first contact.
Since the original file is too large to analyze on a microcomputer, initial analyses are based on a randomly selected 1% sample. In order to have at least one full year of observation before initial psychiatric contact and at least two years after, a 4-year observation “window” was selected for cases first seen during 1976-1979. Because of the relatively small proportion of male patients seen in private practices, we restricted the sample to women aged 15-64. There are no diagnostic data for ambulatory services from private physicians. The final step was to exclude persons with mixed contacts. The cases were divided into three clinical subgroups: fumiZyphysician patients had at least one psychotherapy/counseling service and contact with no other ambulatory or inpatient service; psychiutrist patients had at least one office contact with a private psychiatrist and contact with no other ambulatory or inpatient service; and ECT patients had at least one electroconvulsive treatment. This group may also have had ambulatory services from private psychiatrists or general practitioners. The annual costs were compared of all private medical services (family physician and specialists,
A paired t-test was used to assess the statistical significance of any difference in the total costs before and after the onset of psychiatric care.
Results The psychiatrist and the ECT groups had lower medical costs in the years following first psychiatric contact. The reductions for the psychiatrist group were not statistically significant. The ECT group reductions were far greater than for the psychiatrist group and were statistically significant (t-test = 2.28, p = 0.03) The family physician group had higher medical costs following the start of initial psychotherapy/ counseling. Year 03 costs were less than year 02 but still higher than during year 01. The differences (despite a far larger n in this group) were not statistically significant.
Discussion This is the first “impact” type of study of psychiatric services from family physicians. There
Psychiatric Care by Family Practitioners
are three important factors that might account for the apparent lack of impact of family physician counseling/psychotherapy on medical costs. First, in this study the disorders recognized by the family physicians may have been at a very early stage and therefore of mild severity or of short-limited duration. It is not possible to distinguish the type or severity of disorders in this database nor is it possible to differentiate the therapeutic approach. Recognition and intervention may have occurred so early that there was little opportunity for markedly increased medical costs. The data support this possibility. The pretreatment costs were far less for the family physician group than for the psychiatrist or ECT treated groups. Future impact studies must specify the stage of the disorder, define its severity, and differentiate transient from more durable disorders. Second, in this study patients saw their own family physician. In contrast, in the usual impact study mental health specialists see the patients. Consultation with an outside specialist may be the crucial factor in reducing the use of general health services. The usual consultation with a mental health specialist involves two factors [ll]: 1) the specialist showing an active interest in the patient; and 2) the patient having the opportunity to tell his or her story in a leisurely, unhurried manner. In addition, the consultant may provide a different perspective. The consultation could promote better understanding of the nature of the patient’s symptoms, invoke alternative support systems or start more appropriate treatment. It is worthwhile assessing the consultant factor further in non-mental disorders. Is there a reduction of general medical costs after consultation with nonsurgical consultants such as gastroenterologists, dermatologists, and rheumatologists? Third, there is the additional problem of procedural terminology. The study groups were defined in somewhat different ways, the ECT patients by specific, homogeneous procedure; the psychiatrist patients by contact with a specialist; the family physician group by a less specific procedural item-counseling or medical psychotherapy. It is possible that some of these patients received additional counseling for a physical disorder rather than for a mental disorder. Future studies should determine whether the visit and treatment were primarily for a mental disorder or for further counseling about a physical disorder.
Ideally we need appropriate randomized clinical trials to assess the impact of psychiatric care. However, we can still gain better understanding of the dynamics of family physician interventions from quasi-experimental studies of administrative data bases. Later analyses of this database can include a larger sample, include males and analyze age differentials. They should consider changes in hospital use and the actual amount and duration of psychotherapy/counseling from family physicians. Future research should consider the clinical disorders and office procedures preceding the psychiatric care. Recent reports have emphasized the problems of recognition and therapy of depression in specialist settings. Keller [12] concluded that most individuals did not receive pharmacotherapy long enough or at a sufficiently high dose to produce a therapeutic response. Later, Kupfer and Freedman [13] discussed the need to consider the particulars of specialist treatment, to assess the attitudes of therapists, and to describe the circumstances of treatment decisions. Before we can develop these “circumstance-of-therapy” studies for primary care we need better instruments. Mental disorders seen in primary care do not conform to the classifications and therapeutic approaches provided in specialist settings [ 141. We need new instruments and classifications for primary care settings. With these new instruments we can then begin to determine the relative ability of psychiatrists and family physicians to identify and treat the types of problems commonly seen in general practice.
Conclusions 1. This research supports the general research findings that medical costs are lower after psychiatrists’ care. 2. ECT patients show a marked reduction in their medical costs. 3. Patients with psychotherapy/counseling from family physicians did not show a reduction in overall medical costs. 4. Future studies should include larger samples, consider changes in the pattern of hospital use, determine the actual amount and duration of psychotherapy/counseling from family physicians, and analyze the clinical disorders and office procedures preceding the psychiatric care. 21
A. Richman
References 1. Jones K, Vischi T: Impact of alcohol, drug abuse and
2. 3.
4. 5. 6.
7.
22
mental health treatment on medical care utilization. Med Care 17(Suppl):l-81, 1979 Ursano RJ, Hales RE: A review of brief individual psychotherapies. Am J Psychiatry 143:1507-1517, 1986 Mumford E, Schlesinger HJ, Glass GV, Patrick C, Cuerdon T: A new look at evidence about reduced cost of medical utilization following mental health treatment. Am J Psychiatry 141:1145-1158, 1984 Levitan SJ, Kornfeld DS: Clinical and cost benefits of liaison psychiatry. Am J Psychiatry 138:790-793, 1981 Glass RM, Freedman DX: Psychiatry. JAMA 254: 2281-2283, 1985 Gask L, McGrath G, Goldberg D, Millar T: Improving the psychiatric skills of the experienced family doctor: An evaluation of a group training course. In Mental Disorders in General Health Care Settings: A Research Conference. Battelle Conference Center, Seattle Washington, June 25-26, 1987, Bethesda, MD, NIMH, 1987, pp. 209-211 Clare AQ, Williams I?: A personal view. In Williams P, Clare AW (eds), Psychosocial Disorders in General Practice, London, Academic Press, 1975, pp. 325-332
8. Wilkinson G: Overview of Mental Health Practices in Primary Care Settings, with Recommendations for Further Research. Mental Health Service System Reports DN No. 7. RockviIle, MD, NIMH, 1986 9. Richman A, Brown MG: Reimbursement by medicare for mental health services by general practitioners-Clinical, epidemiologic and cost containment implications of the Canadian experience. In Parron DL, Solomon F (eds), Mental Health Services in Primary Care Settings, Report of a Conference April 23,1979, Washington, DC, NIMH, Mental Health Service System Reports, 1980, pp. 122-130 10. Richman A: Psychiatry. In The Canadian Encyclopedia, 2nd ed. Calgary: Hurtig Publishers, 1988, pp. 1776-1778 11. Shorter E: Bedside Manners: The Troubled History of Doctors and Patients. New York, Simon and Schuster, 1985 12. Keller MB, et al: Treatment received by depressed patients. JAMA 248:1848-1855, 1982 13. Kupfer DJ, Freedman DX: Treatment for depression: ‘Standard’ clinical practice as an unexamined topic. Arch Gen Psychiatry 43:509-511, 1986 14. Barrett J: Case identification for category validation: The challenge of disorder-specific assessment. Compr Psychiatry 27:81-100, 1986
