Private
Psychiatry
Report BY
on
STEVEN
and
Private S.
Accountability:
A Response
\1.I).,
Sl1Rl”STEI\,
\1.P.\.,
CARl.
A. TAL13E,
As NATIONAL HEALTH INSURANCE coverage for mental illness is debated in the coming months, one of the issues will be the role private psychiatry will play in the final plan. The future and structure of mental health services in this country will hinge on the benefit package provided by the plan. A balanced assessment of the current contnibution of private practitioners is necessary in order for the public to be served with quality care at reasonable cost. The American Psychiatric Association’s task force meport, The Present and Future Importance ofPazzerns of Private Psychiatric Practice in the Delivery of Mental Health Services ( I ), is one attempt to assess “the vital role of its private practitioner members in the delivery of mental health services to the American people” (p. v). The report makes several statements regarding the supenionity of the private practice delivery system, including the following: It seems doubtful that there is any health service rendered by a public facility that could not be as, or more, effectively rendered by the private sector of psychiatry from the standpoint of quality and economy. . . . To the extent public can
The authors
integrate
the
are with the National
private
Institute
sector
of
of Mental
psychiatry
under
Health,
Alcohol,
Drug Abuse, and Mental Health Administration, 5600 Fishers Lane, Rockville, Md. 20852. Dr. Sharfstein is Chief, Evaluation Branch, Offlee of Program Development and Analysis. Mr. Taube and Mr. Goldberg are with the Biometry Division, where Mr. Taube is Chief, Survey
and
Reports
Section.
Address
Section, reprint
and
APA
Task
Force
Practice
The authors note that the imminence ofnational health insurance makes it very important to determine the roles, efficiency, and effectiveness ofboth the private and the public sectors ofmental health care. The difficulties in distinguishing public from private care are examined. The authors present estimated distributions ofcare by type ofprovider that differfrom those ofan A PA task force report on private practice. They point out the need f or objective research on the quality ofcare in both sectors and on the effectiveness ofalternative mental health systems, suggesting that public choices should be made on the basis ofcorrect interpretations of reliable data and accountability to those being served.
facilities
to the
Mr. Goldberg
requests
is Chief,
Evaluation
Studies
to Dr. Sharfstein.
Views expressed herein are those of the authors and do not necessarily reflect the opinions, official policies, or positions of NIMH or the Alcohol, Drug Abuse, and Mental Health Administration.
\1)
IRVING
I). GOLI)BERG,
contractual
or
be
better
cost.
(pp.
fee-for-service
served 20,
\1.P.Il.
arrangements,
and
at
the
same
the
or
public
possibly
will
a lower
21)
These conclusions have elicited comments that challenge the quality and economy of organized patterns of care and public policies favoring organized care settings such as community mental healthcentens (2). In this paper we will take issue with some of the task force’s data and their interpretations of the data. We will also deal with issues related to the distinction between public and private care and to accountability, quality asessment, and economic factors. These issues are necessany components in any comparative analysis ofthe onganization of mental health delivery systems, and they must be faced before public policy regarding national health insurance can proceed in a rational and responsible manncr.
DATA
ON
THE
RELATIVE
ROLE
OF
THE
PRIVATE
SECTOR
The task force report presents an analysis of the contnibutions of psychiatrists in private practice to the delivery of mental health services. Their analysis was based on a study that was conducted in the state of Kentucky in 1970 (3). From these data, the report concludes that The tucky delivery cable
The
private
practice
is the
largest
system. to the
seek, each and receive
year,
It is useful
sional
of all
the
possibly
(1,
15)
p.
more
to estimate, half
profession state’s
quite
of
about
psychiatric
care
private
practitioners.
it from
national
emotionally
in the United (1,
practice and
disturbed
be appli-
as the Kentucky survey 5,000,000 persons who
outpatient
meets
health
may
certainty,
the private
ill, and one that
in Ken-
mental
p.
States
uncertainty seems
sector
persons
who
to
of psychia-
inpatient
the service
seek
19)
the end of the report, all role of the private practitioner and we find the statement,
to picture
try as a massive
with
fair
roughly
Finally, near about the relative have disappeared,
half
states
it seems
that
the mentally
as a whole.
later
All in all, suggests,
of the of
finding
This
nation
report
segment
component
service
needs seek
for
of about profes-
help. (1, p. 27) AmJ
Psychiatry
132:1,January
1975
43
PRIVATE
PSYCHIATRY
AND
ACCOUNTABII.ITY
Aside from the statistical hazards inherent in projecting findings from a single state to the nation as a whole, other data on the mental health system that were not cxamined in the report seem to indicate that more modest claims
regarding
psychiatry of Kentucky. lows. Kentucky
the
might An
role
be more examination
of the
private
practice
appropriate, of some
sector
of
even in the state of these data fol-
Estimates
Discussion oftaskforce estimates. culates the number of persons served psychiatrists
in the
United
States
The task annually in the
following
force calby private man-
ner: 1. According to a study by the American Medical Association (7), an average practitioner in psychiatry has 55 patient visits a week and works an average of48 weeks a year(l,p. 16). 2. These figures were multiplied by an unreferenced figure of 8,000 psychiatrists in full-time private practice (8,000 x 48 x 55), yielding a figure of 21,120,000 visits annually to private psychiatrists (1, pp. 3, 18). 3. An unreferenced figure of 300 was used as the number of individuals seen annually pen psychiatrist, which, 44
Am
by the number ofpsychiatnists (8,000), yields a 2,400,000 individuals seen yearly by psychiatnists in private practice ( I, p. 18). We arrived at an estimated national distribution using the task force’s figures and unpublished estimates of mdividuals seen in public and private facilities that we denived from National Institute of Mental Health (NIMH) data (8), adjusted for duplication.’ Of a total of 5,753,000 persons receiving (N =2,400,000)
Data
The most recent year for which the Kentucky Department of Mental Health has published data is 1972; these data relate to state mental hospitals and community mental health centers (4). In order to compare these figures with those for private practice, we will accept for the moment the 1970 survey (3) estimate of 12,300 individuals under the care of private practitioners in Kentucky and assume for the purposes ofillustration that this numben increased by 25 percent between 1970 and 1972 (to 15,375). This provides us with the following picture: Of the total number of individuals under psychiatric cane in Kentucky in 1972 (N=66,254), 23 percent (N= 15,375) were served by private practitioners, 12 percent (N= 7,948) by state mental hospitals, and 65 percent (N= 42,921) by community mental health centers (CMHCs). These data seem to indicate that private practice accounts for a quarter-not a half, as stated in the task force report-of the individuals served annually. This proportion is more consistent with the results of a study by Homnstra and Udell (5), who found (in a seven-county area which included Kansas City, Mo.) that 29 percent of all individuals applying for psychiatric services during a one-year period (1967-1968) were accounted for by the private sector and that 35 percent of all those under psychiatnic care on a given day were accounted for by private psychiatrists. Also of interest in this regard are unpublished data from the psychiatric case register in Monroe County, N.Y. (6), which indicate that of all persons seen in psychiatric settings in that county in 1971, fewer than 20 percent were seen by psychiatrists in private office practice (even after adjusfment for underreporting to the register), and about a third of those seen by the private practitioner were also seen in other psychiatric settings during that year. National
multiplied figure of
I Psychiatry /32.1.January
1975
(N=972,000) 2,381,000) cated
tor
settings
are
in 1971, practice,
not
completely
with
that must the counts
percent (N= are undupli-
be considered for the private
unduplicated.
the episodes people who
episode
42 percent 17 percent
only.)
are several factors these data. First,
tion of represent their
psychiatric care seen in private
in private facilities. and 41 in public facilities. (These data
within
There terpreting
were
the
in were
A
certain
the private-practice admitted, during
private
psychiatrist,
in insec-
propor-
category the course of to
a private
mental health facility (e.g., private general hospital or private psychiatric hospital). Such people would also be counted among the episodes in private facilities, which inflates the total count ofindividuals in the private sector.2 A second problem concerns the validity of the task force
estimate
of
2.4
million
persons
under
the
cane
of
psychiatrists in private practice. A critical issue in this estimate is the task force’s figure of 300 different individuals under cane annually per private psychiatrist.3 Data from various surveys of psychiatrists that were not cited by the task force seem to indicate that 300 is a considenable overestimate (see table I). Modified national estimates. A rough estimate of the number of different patients seen annually by private psychiatnists may be obtained from the unweighted average ofthe results ofthe surveys summarized in table I. If one rejects the data from California (15), where the practice of psychiatry is particularly atypical of the nation as a
‘Facility data on episodes (i.e., the number of people under care at the beginning of a year plus all admission actions during that year) were converted to “individuals” by multiplying the episodes by 0.8, a factor derived from the Maryland Psychiatric Case Register, which indicated that persons in that register had an average of 1.2 episodes ofcare per year.
2An estimate of this overlap is provided by an NIMH study of discharges from general hospital psychiatric units (9) that indicated that 54 percent of the discharges from private general hospital psychiatric units were referred to a private psychiatrist. In addition, another study of private mental hospitals ( 10) indicated that the referral source to the hospital was a private psychiatrist in 45 percent of the cases. Using these proportions, it may be estimated that 2 I 6,000 of the 972,000 estimated episodes for private facilities were referred to or from a private psychiatrist. This number should be subtracted from the total of 3,372,000 persons listed for the private sector (private facilities plus private practitioners). The degree of overlap between the public and private sectors in patients treated is unknown, but probably small, and is therefore ignored for purposes of this discussion.
‘One might also take issue with other estimates used or quoted in the report. For example, the report notes that the AMA study (7) referred to by the task force reported that the average number of hours spent weekly by psychiatrists in providing direct care was 37.3. An APA study ( I I ), however, reported this average to be 3 1 .5 hours a substantial discrepancy.
SHARFSTEIN,
TABLE
TABLE
I
Number Surveys
of Diflerent
Persons
A nnuallv
per
Schulberg(l2) Bahn and associates ( 13) Klee and Wartheri ( 14) Littlestone and Brosn (15) median
because **Estimated
it
was is more from
1963 1963 1965 1966
1964
32 for psvchoanalvsts. representative other
data given
ofprivate
The
Psychiatrist:
Selected
Site
Number of Different Patients Seen per Year
Massachusetts United States Maryland California
135 107 93* 259**
Year Covered by Survey
Authors
*The
Seen
tIgure
practice
for
nonanalsts
is used
in general.
in the study.
whole, the average is 1 12 individuals seen annually pen psychiatrist. (If the California data are included, the average is l49-stiIl only half the figure used in the task force report.) Using this average of I 12 and eliminating the overlap ofan estimated 216,000 patients seen in both private facilities and private office practice, the unduplicated count of persons seen in the public and private 5cctons may be estimated as follows: Ofa total of 4,033,000 psychiatric patients in 1971, 41 percent (N= 1,652,000) were seen in the private sector, and 59 percent (N = 2,381,000) were seen in the public sector. (These figures are unduplicated within sector.) However, this method ofestimating the role ofthe pnivate sector in the provision of mental health services is deficient because it does not take into account the volume and kinds of services given to each person. Table 2 presents the units of service generated annually by the public versus the private sector of psychiatry, based on unpublished NIMH data for 1971. Because inpatient and outpatient services are so different, they are treated separately. (Units of service in table 2 are allocated to the public on private sector according to the ownership of the facility.) The task force estimated that private psychiatrists generate 21,120,000 visits annually. Presumably, this includes the estimated 6,210,000 visits in private mental health facilities shown in table 2. Private office practice visits exclusive of these visits would number 14,910,000. This estimate is almost three and a half times the figure given by the National Center for Health Statistics (NCHS), based on a national sample survey (16). Even if one assumes that the NCHS survey represents an underestimate of 50 percent (resulting from hesitancy about meporting psychiatric cane in a household interview), the modified estimate would be only 6,560,000, as contrasted to the task force estimate of 14,910,000. If we use the modified NCHS estimate of office visits (rather than the task force estimate) and the other estimates for outpatient and inpatient services shown in table 2, we derive the volume of services for the private and public sectors that is summarized in table 3. We find, therefore, that when the volume ofservices is taken into account, the pni-
Annual Private
Volume Psychiatric
of
Inpatient Facilitiesfor
GOLDBERG
and Outpatient 1971
Inpatient Days (in thousands)
of Facilit
Public State and county mental hospitals VA psychiatric hospitals General hospital psychiatric units Federally funded CMHCs Outpatient clinics Total Percent
TABLE
Services
2.171 I , I 82
2,178 2.225 111,932 88
in
Outpatient Visits (in thousands)
95.584 I 1 945
Private Mental hospitals Residential treatment centers for emotionally disturbed children General hospital psychiatric units Outpatient clinics Total Percent
1,219 3,376 3,206 11,154 64)
,,
4,293
506
6,378 4,794
1,661 4.043 6.2 10 36,,
15,465 12’,,
3
Estimated .4 nnual Public and Private
Volume Psychiatric
of
Inpatient Seiting.sjbr
Inpatient
Type
AND
2
Estiniated Public and
Tpc
TAUBE,
of Setting
Private Private Public Total
office practice facilities facilities
*Pris.ate
ofluce practice
the estimate
used
Days
Percent
15,465 I I 1.932 127.397
12 88 100
APA
task
force
Services
Outpatient
Number (in thousands)
visits are based
in the
and Outpatient 1971
on modified report
Number (in thousands)
Visits
Percent
6.560* 6,210 I 1,154 23,924 NCHS
data(l6)
in
27 26 47 100 rather
than
( I).
vate sector accounts for a total of 53 percent of outpatient visits and I 2 percent of inpatient days. The question remains as to how these different units of service should be combined to arrive at a weighted total. A reasonable approach would be to use a weighting based on the cost of a visit in relation to the cost of an inpatient day, which is analogous to the American Hospital Association’s
model
for
combining
outpatient
and
inpatient
services to arrive at “adjusted patient days” (17). On this basis, using the ratio of allowable benefits under the Blue Cross and Blue Shield health insurance program for fedcral employees, we may assume that three outpatient visits arc equivalent to one inpatient day. Thus, dividing the outpatient visits by 3 and adding this to the number of inpatient days, we arrive at a weighted measure of service units. The public sector accounts for 85 percent (N= 1 1 5,650,000) of these units and the private sector for IS percent (N= 19,722,000).
A m J Psychiatrt’
/32:!,
January
1975
45
PRIVATE
PSYCHIATRY
AND
ACCOUNTABII.ITY
Needfor more and different data. The vast difference in the relative role of private psychiatry, when put in terms ofthe volume ofservices as opposed to the number of different individuals seen, is readily apparent from these data. Examining the kinds of services provided by the public and private sectors is also important in evaluating their relative roles. For example, Miles and associates (18) found that 44 percent of the individuals seen by private psychiatrists were seen only for diagnosis. Data are also lacking on the relative efficiencies and effectiveness of different mental health professionals. Social workers, clinical psychologists, psychiatric n unses, and others provide valuable services. Like psychiatrists, these professionals practice in a mix ofpublic and private organized care settings and in private offices. The difficulties in measuring their roles relative to each other and to psychiatrists complicate the issue still further.
PRIVATE
VERSUS
Distinguishing
PUBLIC
Between
CARE:
the Two
FURTHER
ISSUES
Sectors
The distinction between private practice and public came is not as clear as the task force report implies. The loci and organization of psychiatric care are varied, and theme is a complex mixture of public and private funding involved. Direct public support, third-party payments (including Medicare and Medicaid), and out-of-pocket funds all finance different costs ofboth public and private facilities. Like psychiatric facilities, professional providers arc not easily distinguished as public on pnivatc,’since they often work in different cane settings. Psychiatrists do not fall into mutually exclusive categories of those who are salaried and employed in organized psychiatric facilities, either public or private, and those who are engaged in pnivate office practice. While certain psychiatrists do fall into only one or the other of these two groups, many othens are both employed in a public organized setting and engaged in private practice. Furthermore, many psychiatnists who are not employed in an organized psychiatric setting use such settings for their patients’ cane through their staff privileges at a hospital on other facility. The available national data are either utilization data on mental health facilities or data on the activities of psychiatnists as a group. Neither of these data sets enables one to clearly distinguish the boundaries of the private sector. For example, if a psychiatrist sees a patient in his private practice, admits the patient to the psychiatric unit of a city or county hospital, and continues to see the patient on an outpatient basis after his discharge from the hospital, should this patient’s hospital stay be counted as private or public came? NIMH data on discharges from city on county general hospital psychiatric inpatient units (8-10) include such patients in the public category. The task force estimates that private psychiatrists see over 2 million different individuals a year. It neglected to point out, however, that a certain proportion of these psychiatrists are salaried employees in public organized
46
A ml
Psychiatry
/32:1, January
/975
mental health settings and that their patients are therefore treated in the public cane system. The task force report does describe several private onganized care systems (e.g., health maintenance organizations and group practices) as distinct from solo private practice. This distinction is a more useful one than a pnivate/public dichotomy, as it separates different models of mental health care delivery. The efficacy and efficiency of solo versus group or organized came is not spelled out in the report and, despite the proper delineation of several of these organized cane systems as private, one is left with the impression that the task force equated private practice with solo practice. A ccountability,
Efficiency,
and Costs
The most essential issues we must deal with involve the accountability and efficiency of private psychiatry. Accountability to the public for medical cane is an increasingly significant issue as national health insurance becomes an imminent reality. It is not enough to say that higher quality and lower cost care can be delivered by a particular sector of the mental health service system. One must specify what populations are under cane among the range of mental health problems. Will the professional providers agree to be accountable for unmet needs? Who will redistribute mental health resources? The CMHC catchment area concept is an attempt to openationalize this accountability issue. Will private cane systems accept this concept? According to the task force report: To date the private sector has not demonstrated . . . its cato deal . . . with the full range of national mental health problems. . . . Among these areas ofdeficiency may be cited the following: I. Failure to meet the needs ofemotionally disturbed and pacity
mentally ilies.
retarded
children
2.
Failure
to meet
3.
Failure
to
including
meet
psychotics,
syndromes. 4. Failure
adolescents
and
their
fam-
pp.
20,
the
needs
the
health
the
aged,
ofthe
poor.
needs and
of
...
the
victims
chronically of
organic
ill, brain
...
to
make
hard drug addicts, quent and criminal (I,
and
...
any
major
alcoholics, population,
impact
on
the
mentally retarded, and the “criminally
treatment
of
the delininsane.”
21)
If private practice allows the provider to declare almost unilaterally the conditions ofhis practice, especially in regard to whom he will and will not treat, then the accountability of a private came system seems to rest with the provider to the provider. The public cane system, including public mental hospitals and CMHCs, has evolved because of the previously noted failure of the private 5ccton to meet the needs of the groups mentioned by the task force. It is clear that private care systems have not included in the past those populations least able to afford on obtain care. To the extent that national health insunance will enable these groups to get cane, it is incumbent on both the public and private care systems to develop accountable responses to their demands for came. It is also essential that objective research designed to
SHARFSTEIN,
assess the quality ofcare be stepped up and that requisite standards of care be established so that peer review can be more than a ratification of the status quo. The taxpaying public has the right to get the most from its dollar, and private care systems must open themselves for public review and comment. The efficiency ofaltennative mental health delivery systems must be tested in a broad and objective manner. There is no uniform agreement at the present time on cost measures that can be compared from one delivery system to another. Cost of an episode of illness and cost per patient hour or “encounter” must be considered in melation to outcome. Similar services provided by different professionals psychiatrists, psychologists, social workens, nurses, and the “new” professionals-must be compared. Cost studies must take differing patient populations into account, and the cost of team cane must be weighed against the benefits. The savings that result in other sectors of the health and human service system from the utilization of mental health services must be estimated. Cost/benefit logic needs to be applied to indirect services such as consultation and education. The task force asserts that the cost of cane in the pnivate sector is the same as that in the public sector. In support of this statement, the report cites three references. The first (19) contains no data relating to this subjectonly the assertion by the authors that this is the case. The other two references (20, 2 1 ) include discussions of unit costs in public and private facilities and state that they are equivalent. It should be noted, however, that equal unit costs do not necessarily mean that the cost per episode of treatment is equal. One facility may be providing an average of 6 units at unit cost x while another facility is providing an average of 12 units at unit cost x to produce the same result. Many factors, including the nature of the populations and problems served, differences in outputs or results, and definitions of an episode of cane, complicate the assessment of cost. The simplistic approach of the task force does not provide an answer to the question of the relative cost of private versus public care. While it may be that the private sector can provide care more efficiently than the public sector, data supporting this hypothesis are not currently available.
CONCL
US IONS
There are no clear data available to permit adequate assessment of or definitive conclusions about the current relative roles of the public and private sectors, however defined, in the provision of mental health services. Each has a significant mole to play and, as the task force report indicates, a balanced mix of the two is essential. Therefore, it is premature at this time to assent the superiority of private care oven public care. This issue is complex and requires thoughtful distinctions among public and private organized cane systems and solo practice, with public choices being made on the basis of correct interpretations
TAUBE,
AND
GOLDBERG
of reliable data and accountability to the people. The issues we have discussed in this paper remain incompletely resolved. What is clear, however, is that patients need accessible services that are effective and efficient. Representatives of both the public and the private sector of psychiatry would agree that mental illness should not be granted a second-class status by national health insurance proposals and that the night to health includes the right to emotional well-being.
REFERENCES I. Task Force Report 6: The Present and Future Importance of Patterns of Private Psychiatric Practice in the Delivery of Mental Health Services. Washington, DC, American Psychiatric Association, 1973 2. Durgin Fi: Outpatient care (Itr to ed). Psychiatric News, Oct 3, l9’13,p2 3. Survey of Mental Health Needs in Kentucky. Louisville, Kentucky Association of Mental Health and Kentucky Psychiatric Association, 1972 4. Kentucky Department of Mental Health: Patterns of Progress 1971-1972. Frankfort, Ky, Kentucky Department of Mental Health, 1972 5. Hornstra RK, Udell B: Use of psychiatric services and insurance coverage. Hosp Community Psychiatry 24:90-93, 1973 6. Babigian HM: Personal communication. Feb 10. 1974 7. American Medical Association: Reference Data on the Profile of Medical Practice. Chicago, AMA, 972 8. National Institute of Mental Health: Patient Care Episodes in Psychiatric Services: United States 1971. Statistical Note 92. HEW publication HSM-74-655. Washington, DC, US Government Printing Office, 1973 9. National Institute of Mental Health: Referral of Persons to and from General Hospital Psychiatric Inpatient Units: United States 1970 71. Statistical Note 7l. HEW publication HSM-73-9005. Washington, DC, US Government Printing Office, 1973 10. National Institute of Mental Health: Admissions to Private Mental Hospitals: 1970. Statistical Note 75. HEW publication HSM-739005. Washington, DC, US Government Printing Office, I973 I I. Arnhoff FN, Kumbar AH: The Nation’s Psychiatrists-1970 Survey. Washington. DC, Amerian Psychiatric Association, 1973 12. Schulberg HC: Private practice and community mental health. HospCommunity Psychiatry 17:363-366, 1966 13. Bahn AK, Conwell M, Hurley P: Survey of private psychiatric practice. Arch Gen Psychiatry 12:295-302, 1965 14. Klee GD, Warthen J: Survey of private psychiatric practice in Baltimore (unpublished paper) 15. Littlestone R, Brown BM: Private psychiatric practice in Central California (unpublished paper) 16. US Department of Health, Education, and Welfare, National Center for Health Statistics: Physician Visits, Volume and Interval Since Last Visit, United States 1969. Vital and Health Statistics, series 10, no 75. HEW publication HSM-72-I064. Washington, DC, US Government Printing Office, 1972 I7. American Hospital Association: Hospital Statistics 1972. Chicago, AHA, l973,p6 18. Miles HC, Gardner EA, Bodian C, et al: A cumulative survey of all psychiatric experience in Monroe County, NY. Psychiatr Q 38: 458-487, 1964 l9. Vaughan WT Jr. Newman DE, Levy A, et aI: The private practice ofcommunity psychiatry. Am J Psychiatry 130:24-27, 1973 20. Alexander Ri, Sheeley MC: Cost per hour for delivery ofservice in a community mental health center. Dis Nerv Syst 32:769-776, 1971 21. Goodwin IH, Rosenblum AE: A method of measuring and cornparing costs in mental health clinics. Hosp Community Psychiatry 23:63-65, 1972
Am
J P.sychiairy
132.!,
January
1975
47
Psychiatry
Report BY
on
STEVEN
and
Private S.
Accountability:
A Response
\1.I).,
Sl1Rl”STEI\,
\1.P.\.,
CARl.
A. TAL13E,
As NATIONAL HEALTH INSURANCE coverage for mental illness is debated in the coming months, one of the issues will be the role private psychiatry will play in the final plan. The future and structure of mental health services in this country will hinge on the benefit package provided by the plan. A balanced assessment of the current contnibution of private practitioners is necessary in order for the public to be served with quality care at reasonable cost. The American Psychiatric Association’s task force meport, The Present and Future Importance ofPazzerns of Private Psychiatric Practice in the Delivery of Mental Health Services ( I ), is one attempt to assess “the vital role of its private practitioner members in the delivery of mental health services to the American people” (p. v). The report makes several statements regarding the supenionity of the private practice delivery system, including the following: It seems doubtful that there is any health service rendered by a public facility that could not be as, or more, effectively rendered by the private sector of psychiatry from the standpoint of quality and economy. . . . To the extent public can
The authors
integrate
the
are with the National
private
Institute
sector
of
of Mental
psychiatry
under
Health,
Alcohol,
Drug Abuse, and Mental Health Administration, 5600 Fishers Lane, Rockville, Md. 20852. Dr. Sharfstein is Chief, Evaluation Branch, Offlee of Program Development and Analysis. Mr. Taube and Mr. Goldberg are with the Biometry Division, where Mr. Taube is Chief, Survey
and
Reports
Section.
Address
Section, reprint
and
APA
Task
Force
Practice
The authors note that the imminence ofnational health insurance makes it very important to determine the roles, efficiency, and effectiveness ofboth the private and the public sectors ofmental health care. The difficulties in distinguishing public from private care are examined. The authors present estimated distributions ofcare by type ofprovider that differfrom those ofan A PA task force report on private practice. They point out the need f or objective research on the quality ofcare in both sectors and on the effectiveness ofalternative mental health systems, suggesting that public choices should be made on the basis ofcorrect interpretations of reliable data and accountability to those being served.
facilities
to the
Mr. Goldberg
requests
is Chief,
Evaluation
Studies
to Dr. Sharfstein.
Views expressed herein are those of the authors and do not necessarily reflect the opinions, official policies, or positions of NIMH or the Alcohol, Drug Abuse, and Mental Health Administration.
\1)
IRVING
I). GOLI)BERG,
contractual
or
be
better
cost.
(pp.
fee-for-service
served 20,
\1.P.Il.
arrangements,
and
at
the
same
the
or
public
possibly
will
a lower
21)
These conclusions have elicited comments that challenge the quality and economy of organized patterns of care and public policies favoring organized care settings such as community mental healthcentens (2). In this paper we will take issue with some of the task force’s data and their interpretations of the data. We will also deal with issues related to the distinction between public and private care and to accountability, quality asessment, and economic factors. These issues are necessany components in any comparative analysis ofthe onganization of mental health delivery systems, and they must be faced before public policy regarding national health insurance can proceed in a rational and responsible manncr.
DATA
ON
THE
RELATIVE
ROLE
OF
THE
PRIVATE
SECTOR
The task force report presents an analysis of the contnibutions of psychiatrists in private practice to the delivery of mental health services. Their analysis was based on a study that was conducted in the state of Kentucky in 1970 (3). From these data, the report concludes that The tucky delivery cable
The
private
practice
is the
largest
system. to the
seek, each and receive
year,
It is useful
sional
of all
the
possibly
(1,
15)
p.
more
to estimate, half
profession state’s
quite
of
about
psychiatric
care
private
practitioners.
it from
national
emotionally
in the United (1,
practice and
disturbed
be appli-
as the Kentucky survey 5,000,000 persons who
outpatient
meets
health
may
certainty,
the private
ill, and one that
in Ken-
mental
p.
States
uncertainty seems
sector
persons
who
to
of psychia-
inpatient
the service
seek
19)
the end of the report, all role of the private practitioner and we find the statement,
to picture
try as a massive
with
fair
roughly
Finally, near about the relative have disappeared,
half
states
it seems
that
the mentally
as a whole.
later
All in all, suggests,
of the of
finding
This
nation
report
segment
component
service
needs seek
for
of about profes-
help. (1, p. 27) AmJ
Psychiatry
132:1,January
1975
43
PRIVATE
PSYCHIATRY
AND
ACCOUNTABII.ITY
Aside from the statistical hazards inherent in projecting findings from a single state to the nation as a whole, other data on the mental health system that were not cxamined in the report seem to indicate that more modest claims
regarding
psychiatry of Kentucky. lows. Kentucky
the
might An
role
be more examination
of the
private
practice
appropriate, of some
sector
of
even in the state of these data fol-
Estimates
Discussion oftaskforce estimates. culates the number of persons served psychiatrists
in the
United
States
The task annually in the
following
force calby private man-
ner: 1. According to a study by the American Medical Association (7), an average practitioner in psychiatry has 55 patient visits a week and works an average of48 weeks a year(l,p. 16). 2. These figures were multiplied by an unreferenced figure of 8,000 psychiatrists in full-time private practice (8,000 x 48 x 55), yielding a figure of 21,120,000 visits annually to private psychiatrists (1, pp. 3, 18). 3. An unreferenced figure of 300 was used as the number of individuals seen annually pen psychiatrist, which, 44
Am
by the number ofpsychiatnists (8,000), yields a 2,400,000 individuals seen yearly by psychiatnists in private practice ( I, p. 18). We arrived at an estimated national distribution using the task force’s figures and unpublished estimates of mdividuals seen in public and private facilities that we denived from National Institute of Mental Health (NIMH) data (8), adjusted for duplication.’ Of a total of 5,753,000 persons receiving (N =2,400,000)
Data
The most recent year for which the Kentucky Department of Mental Health has published data is 1972; these data relate to state mental hospitals and community mental health centers (4). In order to compare these figures with those for private practice, we will accept for the moment the 1970 survey (3) estimate of 12,300 individuals under the care of private practitioners in Kentucky and assume for the purposes ofillustration that this numben increased by 25 percent between 1970 and 1972 (to 15,375). This provides us with the following picture: Of the total number of individuals under psychiatric cane in Kentucky in 1972 (N=66,254), 23 percent (N= 15,375) were served by private practitioners, 12 percent (N= 7,948) by state mental hospitals, and 65 percent (N= 42,921) by community mental health centers (CMHCs). These data seem to indicate that private practice accounts for a quarter-not a half, as stated in the task force report-of the individuals served annually. This proportion is more consistent with the results of a study by Homnstra and Udell (5), who found (in a seven-county area which included Kansas City, Mo.) that 29 percent of all individuals applying for psychiatric services during a one-year period (1967-1968) were accounted for by the private sector and that 35 percent of all those under psychiatnic care on a given day were accounted for by private psychiatrists. Also of interest in this regard are unpublished data from the psychiatric case register in Monroe County, N.Y. (6), which indicate that of all persons seen in psychiatric settings in that county in 1971, fewer than 20 percent were seen by psychiatrists in private office practice (even after adjusfment for underreporting to the register), and about a third of those seen by the private practitioner were also seen in other psychiatric settings during that year. National
multiplied figure of
I Psychiatry /32.1.January
1975
(N=972,000) 2,381,000) cated
tor
settings
are
in 1971, practice,
not
completely
with
that must the counts
percent (N= are undupli-
be considered for the private
unduplicated.
the episodes people who
episode
42 percent 17 percent
only.)
are several factors these data. First,
tion of represent their
psychiatric care seen in private
in private facilities. and 41 in public facilities. (These data
within
There terpreting
were
the
in were
A
certain
the private-practice admitted, during
private
psychiatrist,
in insec-
propor-
category the course of to
a private
mental health facility (e.g., private general hospital or private psychiatric hospital). Such people would also be counted among the episodes in private facilities, which inflates the total count ofindividuals in the private sector.2 A second problem concerns the validity of the task force
estimate
of
2.4
million
persons
under
the
cane
of
psychiatrists in private practice. A critical issue in this estimate is the task force’s figure of 300 different individuals under cane annually per private psychiatrist.3 Data from various surveys of psychiatrists that were not cited by the task force seem to indicate that 300 is a considenable overestimate (see table I). Modified national estimates. A rough estimate of the number of different patients seen annually by private psychiatnists may be obtained from the unweighted average ofthe results ofthe surveys summarized in table I. If one rejects the data from California (15), where the practice of psychiatry is particularly atypical of the nation as a
‘Facility data on episodes (i.e., the number of people under care at the beginning of a year plus all admission actions during that year) were converted to “individuals” by multiplying the episodes by 0.8, a factor derived from the Maryland Psychiatric Case Register, which indicated that persons in that register had an average of 1.2 episodes ofcare per year.
2An estimate of this overlap is provided by an NIMH study of discharges from general hospital psychiatric units (9) that indicated that 54 percent of the discharges from private general hospital psychiatric units were referred to a private psychiatrist. In addition, another study of private mental hospitals ( 10) indicated that the referral source to the hospital was a private psychiatrist in 45 percent of the cases. Using these proportions, it may be estimated that 2 I 6,000 of the 972,000 estimated episodes for private facilities were referred to or from a private psychiatrist. This number should be subtracted from the total of 3,372,000 persons listed for the private sector (private facilities plus private practitioners). The degree of overlap between the public and private sectors in patients treated is unknown, but probably small, and is therefore ignored for purposes of this discussion.
‘One might also take issue with other estimates used or quoted in the report. For example, the report notes that the AMA study (7) referred to by the task force reported that the average number of hours spent weekly by psychiatrists in providing direct care was 37.3. An APA study ( I I ), however, reported this average to be 3 1 .5 hours a substantial discrepancy.
SHARFSTEIN,
TABLE
TABLE
I
Number Surveys
of Diflerent
Persons
A nnuallv
per
Schulberg(l2) Bahn and associates ( 13) Klee and Wartheri ( 14) Littlestone and Brosn (15) median
because **Estimated
it
was is more from
1963 1963 1965 1966
1964
32 for psvchoanalvsts. representative other
data given
ofprivate
The
Psychiatrist:
Selected
Site
Number of Different Patients Seen per Year
Massachusetts United States Maryland California
135 107 93* 259**
Year Covered by Survey
Authors
*The
Seen
tIgure
practice
for
nonanalsts
is used
in general.
in the study.
whole, the average is 1 12 individuals seen annually pen psychiatrist. (If the California data are included, the average is l49-stiIl only half the figure used in the task force report.) Using this average of I 12 and eliminating the overlap ofan estimated 216,000 patients seen in both private facilities and private office practice, the unduplicated count of persons seen in the public and private 5cctons may be estimated as follows: Ofa total of 4,033,000 psychiatric patients in 1971, 41 percent (N= 1,652,000) were seen in the private sector, and 59 percent (N = 2,381,000) were seen in the public sector. (These figures are unduplicated within sector.) However, this method ofestimating the role ofthe pnivate sector in the provision of mental health services is deficient because it does not take into account the volume and kinds of services given to each person. Table 2 presents the units of service generated annually by the public versus the private sector of psychiatry, based on unpublished NIMH data for 1971. Because inpatient and outpatient services are so different, they are treated separately. (Units of service in table 2 are allocated to the public on private sector according to the ownership of the facility.) The task force estimated that private psychiatrists generate 21,120,000 visits annually. Presumably, this includes the estimated 6,210,000 visits in private mental health facilities shown in table 2. Private office practice visits exclusive of these visits would number 14,910,000. This estimate is almost three and a half times the figure given by the National Center for Health Statistics (NCHS), based on a national sample survey (16). Even if one assumes that the NCHS survey represents an underestimate of 50 percent (resulting from hesitancy about meporting psychiatric cane in a household interview), the modified estimate would be only 6,560,000, as contrasted to the task force estimate of 14,910,000. If we use the modified NCHS estimate of office visits (rather than the task force estimate) and the other estimates for outpatient and inpatient services shown in table 2, we derive the volume of services for the private and public sectors that is summarized in table 3. We find, therefore, that when the volume ofservices is taken into account, the pni-
Annual Private
Volume Psychiatric
of
Inpatient Facilitiesfor
GOLDBERG
and Outpatient 1971
Inpatient Days (in thousands)
of Facilit
Public State and county mental hospitals VA psychiatric hospitals General hospital psychiatric units Federally funded CMHCs Outpatient clinics Total Percent
TABLE
Services
2.171 I , I 82
2,178 2.225 111,932 88
in
Outpatient Visits (in thousands)
95.584 I 1 945
Private Mental hospitals Residential treatment centers for emotionally disturbed children General hospital psychiatric units Outpatient clinics Total Percent
1,219 3,376 3,206 11,154 64)
,,
4,293
506
6,378 4,794
1,661 4.043 6.2 10 36,,
15,465 12’,,
3
Estimated .4 nnual Public and Private
Volume Psychiatric
of
Inpatient Seiting.sjbr
Inpatient
Type
AND
2
Estiniated Public and
Tpc
TAUBE,
of Setting
Private Private Public Total
office practice facilities facilities
*Pris.ate
ofluce practice
the estimate
used
Days
Percent
15,465 I I 1.932 127.397
12 88 100
APA
task
force
Services
Outpatient
Number (in thousands)
visits are based
in the
and Outpatient 1971
on modified report
Number (in thousands)
Visits
Percent
6.560* 6,210 I 1,154 23,924 NCHS
data(l6)
in
27 26 47 100 rather
than
( I).
vate sector accounts for a total of 53 percent of outpatient visits and I 2 percent of inpatient days. The question remains as to how these different units of service should be combined to arrive at a weighted total. A reasonable approach would be to use a weighting based on the cost of a visit in relation to the cost of an inpatient day, which is analogous to the American Hospital Association’s
model
for
combining
outpatient
and
inpatient
services to arrive at “adjusted patient days” (17). On this basis, using the ratio of allowable benefits under the Blue Cross and Blue Shield health insurance program for fedcral employees, we may assume that three outpatient visits arc equivalent to one inpatient day. Thus, dividing the outpatient visits by 3 and adding this to the number of inpatient days, we arrive at a weighted measure of service units. The public sector accounts for 85 percent (N= 1 1 5,650,000) of these units and the private sector for IS percent (N= 19,722,000).
A m J Psychiatrt’
/32:!,
January
1975
45
PRIVATE
PSYCHIATRY
AND
ACCOUNTABII.ITY
Needfor more and different data. The vast difference in the relative role of private psychiatry, when put in terms ofthe volume ofservices as opposed to the number of different individuals seen, is readily apparent from these data. Examining the kinds of services provided by the public and private sectors is also important in evaluating their relative roles. For example, Miles and associates (18) found that 44 percent of the individuals seen by private psychiatrists were seen only for diagnosis. Data are also lacking on the relative efficiencies and effectiveness of different mental health professionals. Social workers, clinical psychologists, psychiatric n unses, and others provide valuable services. Like psychiatrists, these professionals practice in a mix ofpublic and private organized care settings and in private offices. The difficulties in measuring their roles relative to each other and to psychiatrists complicate the issue still further.
PRIVATE
VERSUS
Distinguishing
PUBLIC
Between
CARE:
the Two
FURTHER
ISSUES
Sectors
The distinction between private practice and public came is not as clear as the task force report implies. The loci and organization of psychiatric care are varied, and theme is a complex mixture of public and private funding involved. Direct public support, third-party payments (including Medicare and Medicaid), and out-of-pocket funds all finance different costs ofboth public and private facilities. Like psychiatric facilities, professional providers arc not easily distinguished as public on pnivatc,’since they often work in different cane settings. Psychiatrists do not fall into mutually exclusive categories of those who are salaried and employed in organized psychiatric facilities, either public or private, and those who are engaged in pnivate office practice. While certain psychiatrists do fall into only one or the other of these two groups, many othens are both employed in a public organized setting and engaged in private practice. Furthermore, many psychiatnists who are not employed in an organized psychiatric setting use such settings for their patients’ cane through their staff privileges at a hospital on other facility. The available national data are either utilization data on mental health facilities or data on the activities of psychiatnists as a group. Neither of these data sets enables one to clearly distinguish the boundaries of the private sector. For example, if a psychiatrist sees a patient in his private practice, admits the patient to the psychiatric unit of a city or county hospital, and continues to see the patient on an outpatient basis after his discharge from the hospital, should this patient’s hospital stay be counted as private or public came? NIMH data on discharges from city on county general hospital psychiatric inpatient units (8-10) include such patients in the public category. The task force estimates that private psychiatrists see over 2 million different individuals a year. It neglected to point out, however, that a certain proportion of these psychiatrists are salaried employees in public organized
46
A ml
Psychiatry
/32:1, January
/975
mental health settings and that their patients are therefore treated in the public cane system. The task force report does describe several private onganized care systems (e.g., health maintenance organizations and group practices) as distinct from solo private practice. This distinction is a more useful one than a pnivate/public dichotomy, as it separates different models of mental health care delivery. The efficacy and efficiency of solo versus group or organized came is not spelled out in the report and, despite the proper delineation of several of these organized cane systems as private, one is left with the impression that the task force equated private practice with solo practice. A ccountability,
Efficiency,
and Costs
The most essential issues we must deal with involve the accountability and efficiency of private psychiatry. Accountability to the public for medical cane is an increasingly significant issue as national health insurance becomes an imminent reality. It is not enough to say that higher quality and lower cost care can be delivered by a particular sector of the mental health service system. One must specify what populations are under cane among the range of mental health problems. Will the professional providers agree to be accountable for unmet needs? Who will redistribute mental health resources? The CMHC catchment area concept is an attempt to openationalize this accountability issue. Will private cane systems accept this concept? According to the task force report: To date the private sector has not demonstrated . . . its cato deal . . . with the full range of national mental health problems. . . . Among these areas ofdeficiency may be cited the following: I. Failure to meet the needs ofemotionally disturbed and pacity
mentally ilies.
retarded
children
2.
Failure
to meet
3.
Failure
to
including
meet
psychotics,
syndromes. 4. Failure
adolescents
and
their
fam-
pp.
20,
the
needs
the
health
the
aged,
ofthe
poor.
needs and
of
...
the
victims
chronically of
organic
ill, brain
...
to
make
hard drug addicts, quent and criminal (I,
and
...
any
major
alcoholics, population,
impact
on
the
mentally retarded, and the “criminally
treatment
of
the delininsane.”
21)
If private practice allows the provider to declare almost unilaterally the conditions ofhis practice, especially in regard to whom he will and will not treat, then the accountability of a private came system seems to rest with the provider to the provider. The public cane system, including public mental hospitals and CMHCs, has evolved because of the previously noted failure of the private 5ccton to meet the needs of the groups mentioned by the task force. It is clear that private care systems have not included in the past those populations least able to afford on obtain care. To the extent that national health insunance will enable these groups to get cane, it is incumbent on both the public and private care systems to develop accountable responses to their demands for came. It is also essential that objective research designed to
SHARFSTEIN,
assess the quality ofcare be stepped up and that requisite standards of care be established so that peer review can be more than a ratification of the status quo. The taxpaying public has the right to get the most from its dollar, and private care systems must open themselves for public review and comment. The efficiency ofaltennative mental health delivery systems must be tested in a broad and objective manner. There is no uniform agreement at the present time on cost measures that can be compared from one delivery system to another. Cost of an episode of illness and cost per patient hour or “encounter” must be considered in melation to outcome. Similar services provided by different professionals psychiatrists, psychologists, social workens, nurses, and the “new” professionals-must be compared. Cost studies must take differing patient populations into account, and the cost of team cane must be weighed against the benefits. The savings that result in other sectors of the health and human service system from the utilization of mental health services must be estimated. Cost/benefit logic needs to be applied to indirect services such as consultation and education. The task force asserts that the cost of cane in the pnivate sector is the same as that in the public sector. In support of this statement, the report cites three references. The first (19) contains no data relating to this subjectonly the assertion by the authors that this is the case. The other two references (20, 2 1 ) include discussions of unit costs in public and private facilities and state that they are equivalent. It should be noted, however, that equal unit costs do not necessarily mean that the cost per episode of treatment is equal. One facility may be providing an average of 6 units at unit cost x while another facility is providing an average of 12 units at unit cost x to produce the same result. Many factors, including the nature of the populations and problems served, differences in outputs or results, and definitions of an episode of cane, complicate the assessment of cost. The simplistic approach of the task force does not provide an answer to the question of the relative cost of private versus public care. While it may be that the private sector can provide care more efficiently than the public sector, data supporting this hypothesis are not currently available.
CONCL
US IONS
There are no clear data available to permit adequate assessment of or definitive conclusions about the current relative roles of the public and private sectors, however defined, in the provision of mental health services. Each has a significant mole to play and, as the task force report indicates, a balanced mix of the two is essential. Therefore, it is premature at this time to assent the superiority of private care oven public care. This issue is complex and requires thoughtful distinctions among public and private organized cane systems and solo practice, with public choices being made on the basis of correct interpretations
TAUBE,
AND
GOLDBERG
of reliable data and accountability to the people. The issues we have discussed in this paper remain incompletely resolved. What is clear, however, is that patients need accessible services that are effective and efficient. Representatives of both the public and the private sector of psychiatry would agree that mental illness should not be granted a second-class status by national health insurance proposals and that the night to health includes the right to emotional well-being.
REFERENCES I. Task Force Report 6: The Present and Future Importance of Patterns of Private Psychiatric Practice in the Delivery of Mental Health Services. Washington, DC, American Psychiatric Association, 1973 2. Durgin Fi: Outpatient care (Itr to ed). Psychiatric News, Oct 3, l9’13,p2 3. Survey of Mental Health Needs in Kentucky. Louisville, Kentucky Association of Mental Health and Kentucky Psychiatric Association, 1972 4. Kentucky Department of Mental Health: Patterns of Progress 1971-1972. Frankfort, Ky, Kentucky Department of Mental Health, 1972 5. Hornstra RK, Udell B: Use of psychiatric services and insurance coverage. Hosp Community Psychiatry 24:90-93, 1973 6. Babigian HM: Personal communication. Feb 10. 1974 7. American Medical Association: Reference Data on the Profile of Medical Practice. Chicago, AMA, 972 8. National Institute of Mental Health: Patient Care Episodes in Psychiatric Services: United States 1971. Statistical Note 92. HEW publication HSM-74-655. Washington, DC, US Government Printing Office, 1973 9. National Institute of Mental Health: Referral of Persons to and from General Hospital Psychiatric Inpatient Units: United States 1970 71. Statistical Note 7l. HEW publication HSM-73-9005. Washington, DC, US Government Printing Office, 1973 10. National Institute of Mental Health: Admissions to Private Mental Hospitals: 1970. Statistical Note 75. HEW publication HSM-739005. Washington, DC, US Government Printing Office, I973 I I. Arnhoff FN, Kumbar AH: The Nation’s Psychiatrists-1970 Survey. Washington. DC, Amerian Psychiatric Association, 1973 12. Schulberg HC: Private practice and community mental health. HospCommunity Psychiatry 17:363-366, 1966 13. Bahn AK, Conwell M, Hurley P: Survey of private psychiatric practice. Arch Gen Psychiatry 12:295-302, 1965 14. Klee GD, Warthen J: Survey of private psychiatric practice in Baltimore (unpublished paper) 15. Littlestone R, Brown BM: Private psychiatric practice in Central California (unpublished paper) 16. US Department of Health, Education, and Welfare, National Center for Health Statistics: Physician Visits, Volume and Interval Since Last Visit, United States 1969. Vital and Health Statistics, series 10, no 75. HEW publication HSM-72-I064. Washington, DC, US Government Printing Office, 1972 I7. American Hospital Association: Hospital Statistics 1972. Chicago, AHA, l973,p6 18. Miles HC, Gardner EA, Bodian C, et al: A cumulative survey of all psychiatric experience in Monroe County, NY. Psychiatr Q 38: 458-487, 1964 l9. Vaughan WT Jr. Newman DE, Levy A, et aI: The private practice ofcommunity psychiatry. Am J Psychiatry 130:24-27, 1973 20. Alexander Ri, Sheeley MC: Cost per hour for delivery ofservice in a community mental health center. Dis Nerv Syst 32:769-776, 1971 21. Goodwin IH, Rosenblum AE: A method of measuring and cornparing costs in mental health clinics. Hosp Community Psychiatry 23:63-65, 1972
Am
J P.sychiairy
132.!,
January
1975
47
