Am
J Psychiatry
The
135:3,
March
Evolution
1978
BRIEF
of Psychiatric
Services
in a Health
COMMUNICATIONS
Maintenance
Organization BY
THOMAS
The
authors
E.
BITTKER,
M.D.,
AND
SCOTT
IDZOREK,
describe a prepaid mental health service program in tv/tic/i outpatient referrals ti’ere 34. 7 per 1,000 members per month, tile hospital admission rate ti’as .80 admissions per 1 ,000 members per year, and the average length ofhospital sun’ it’as 5.03 days. The’ offer se t’eral explanations for theirfinding that the costsfor mental health services in this progran appear latter t/zaiz those infee-for-seri’ice programs.
PSYCHIATRIC PRACTICE in a health maintenance organization (HMO) accentuates the contrast between psychiatny’s emerging role and the role for which many psychiatrists have been trained. Because of the way that financing mental health cane shapes psychiatric practice, there are some important distinctions between practicing in an HMO and in the fee-for-service, private practice sector. Our focus will be on these distinctions as we present the history, current pnocedures, and utilization data for a psychiatric service in an HMO. We hope that our experiences will complement the growing body of literature on the subject (1-4).
DESCRIPTION
OF
THE
PROGRAM
The
Arizona Health Plan (AHP) began seeing its patients in October 1972, when there were the equivalent of 3#{189}full-time physicians ministering to the medical needs of 3,800 patients. Within a year the patient population had grown to 14,000 and the staff to the equivalent of 13 full-time physicians. By November 1976 the total patient enrollment had surpassed 36,000, and there were 35 full-time physicians on the staff. The AHP initially referred patients needing mental health care to outside consultants. Soon a social worker was hired to provide such services. However, it befirst
Dr. Bittker is Director. Division and Chairman of the Department zona Health Plan, P.O. Box 5000, is on the staff of the Department Arizona Health Plan.
The
authors
would
like to thank
assisting providing
in data analysis for historical material,
Matilsky
for help
in manuscript
of Health Maintenance Services, of Mental Health Services, AriPhoenix, Ariz. 85010. Dr. Idzorek of Mental Health Services at the
Donald
Carroll
and Mary
this report, Donald Schaller, and Christine Bittken and
Eplett
for
M.D., for Many Lynn
preparation.
0002-953X/78/0003-0339$0.45
© 1978
M.D.
came apparent that patient needs as well as physician needs for consultation required the involvement of a psychiatrist. In February 1974 a full-time psychiatric consultant was hired, and by November 1976 the Mental Health Services Department (MHSD) included 2 full-time psychiatrists, 2 full-time psychologists, the equivalent of 1#{189} full-time social workers and 1#{189} fulltime psychiatric nurses, and 3 other part-time professionals. In January 1976 the MHSD fostered the development of a free-standing substance abuse program staffed by a family practice physician with considenable experience and interest in the field of alcoholism and drug abuse plus a social worker with a masten’s degree and a registered nurse. Afterjoining the AHP, all members are assigned to a primary medical panel that assumes responsibility for the coordination of medical care. The typical panel is composed of 3 family practice physicians, 3 nurses, and a nurse-practitioner. One of the physicians on the panel is usually considered the patient’s primary medical provider. All members of the AHP are entitled to the same mental health benefit package. This package provides for 20 outpatient individual, couple, or family therapy visits or, as an alternative, 40 group therapy visits per year. Thirty inpatient hospital days or, as an alternative, 60 partial hospitalization days are provided per year. The benefit package limits AHP involvement to treatment ofemotional problems thought to be responsive to time-limited intervention. The AHP pays 100% ofthe cost ofall allowable hospitalizations and charges $2.00 per patient pen outpatient visit up to a total of $6.00 per family unit per visit. Although the AHP does not operate an inpatient service, the MHSD staff supervises and manages all member inpatients in private hospitals. The primary medical provider or a colleague on his or her panel refers most of the patients seen in the MHSD. In addition to this route for referrals, patients are referred by consulting physicians, by the Urgent Care Unit (emergency room), by the Health Evaluation Department, and, occasionally (following a chart review), by the Medical Audit Committee. In this latter case, patients who demonstrate a profile indicative of emotional problems (e.g., multiple drug use, alcoholism, or ovenutilization of medical resources) are referred following consultation with the primary medical provider. However the patient is referred, the primary medical panel is advised of the referral, and, if it has American
Psychiatric
Association
339
BRIEF
COMMUNICATIONS
Am
not already been done, an up-to-date health evaluation (multiphasic health screening examination) is scheduled. The referral process represents a collaboration between the primary medical panel and the MHSD. In most cases, the patient is referred back to the primary panel after being seen by the mental health provider and receiving treatment or consultation. Because of the restrictions on psychiatric benefits, the MHSD stresses time-limited treatment programs. Patients are evaluated to determine whether their psychiatric needs can be met on a short-term, goal-oriented basis or on an infrequent, periodic basis over an extended period of time. If it is apparent that the problem cannot be satisfactorily addressed within a timelimited treatment program, the patient or family is mefemned to an appropriate community service or to a pnivate psychotherapist. The AHP does not assume financial responsibility for these referrals. At the time of the referral to the MHSD, nonpsychotic patients undergo a preintake evaluation that includes a personal history questionnaire, the MMPI, the Symptom Check List-90, the Beck Depression Inventory, and the Target Symptom Questionnaire. When a child is the identified patient, a behavioral mating scale and a developmental history are requested from the parents and from the school. Couples are frequently invited to complete a behaviorally oriented precounseling inventory. Patients typically complete these written evaluations within 5 days of the initial referral. Within 10 days of the referral. the patient or patients have a 90-minute intake appointment with a mental health provider. There is no waiting list, and emergency evaluations can be done immediately. As part of the intake process, the mental health professional determines whether or not the patient or family has problems amenable to treatment within the benefit package, assesses the clinical situation, and lays the groundwork for the possible establishment of a treatment contract. Much emphasis is placed on goal setting, verbal contracting (e.g., antisuicide contracting), and limit-setting techniques (e.g. the use of registered letters to summarize agreements). Treatment may be exploratory. supportive, on educational, or it may involve combined approaches. Depending on the demands of the problem and the skills required, a single provider may see the patient or a number of different providers may collaborate. In evaluating the patient or family system, treatment objectives reflect the following priority issues: 1) What is the patient or family requesting? 2) What is the patient willing to invest in the treatment process? 3) What can be accomplished on a time-limited basis? 4) How has the patient or family coped before coming for treatment? 5) What resources are available to assist the patient or his or her family in coping with the problems presented? 6) What was the patient or family’s premorbid level of functioning? 7) How can homeostasis be restored as promptly as possible while minimizing regression? 8) To what degree is the patient or family willing to assume responsibility for the work in ,
340
J Psychiatry
135:3, March
1978
their treatment? 9) Having assessed all of the above, what resources is the mental health provider willing to commit on behalf of the AHP in treating the problem presented? Exploratory treatment requires a motivated patient who acknowledges responsibility for himself on herself, who desires to change, and who is sufficiently aware of his or her own feelings and impact on others to use the therapeutic relationship in behalf of the change process. Short-term supportive therapy mequires patients with well-delineated problems emerging from a life transition, a history ofcoping with other life transitions, and the ability to form positive rapport with the mental health professional. Long-term supportive therapy can be offered when maintenance is the primary goal for the patient. Most patients in short-term therapy complete treatment within 6-12 psychotherapy sessions, and most patients in long-term therapy are seen approximately once a month over an indefinite period of time. Of 500 consecutive office encounters analyzed for the month ofOctoben 1976, 237 (47.4%) were seen as individuals, 127 (25.4%) as families or couples, and 136 (27.2%) as groups on in educational sessions. In addition to the time-limited psychotherapy treatment programs we offer biofeedback training. medication clinics, women’s consciousness groups, assertive training, stress management workshops, and headache prevention clinics. Hospitalization is rarely used as a treatment altemnative. Hospitalization typically involves a patient whose social resources are insufficient or unwilling to provide support during the time when the mental health provider is not available. As an alternative to hospitalization, we have developed an ad hoc crisis team. Participants in this crisis team include the primamy mental health provider, a psychiatric consultant, collateral providers ifnecessary, and a nurse trained in public health provided by the Field Health Nursing Department of the AHP. Using this approach patients may be seen daily, and the nurse can make home visits. Thus, it is often possible for the patient and his or her family to be comprehensively assessed and supported on an outpatient basis. ,
RESULTS
During the first 3 years of its functioning, the referral rate to the MHSD grew gradually. In 1973, before the development of a full-time program, there were 18 referrals pen 1,000 patients. In 1974 the rate increased to 24 per 1,000, and in 1975 the rate climbed to 34.1 per 1.000. Through July 1976 the mate plateaued at 34.7 per I ,000 members per year. In addition, the total number of mental-health-related office visits to the MHSD have been gradually increasing. In 1975 there were 543 office visits pen month, on 21.7 mental health office visits per I ,000 enrollees per month. In the first 6 months of 1976 theme was an average of 771 office visits per
Am
J Psychiatry
135:3,
March
1978
BRIEF
month, or 26 visits per 1,000 members per month. The average number of office visits pen referral increased from 7.61 visits pen referral in 1975 to 8.72 visits per referral in 1976. Since January 1975 our inpatient referral mate has been .80 admissions pen 1 ,000 members pen year. The average length of stay per admission has been 5.03 days. A review of 100 patient charts in the MHSD revealed the following data: 1) 55% of the patients were referred by the Family Practice Department, 14% by the Pediatric Department, and the remaining 31% from various other sources; 2) 59% ofthe patients were 2045 years ofage, 15% were 46-60, 10% were 3-12, 8% were 13-19, and 8% were oven 60; the youngest patient was 3 years old, and the oldest was 62; 3) 21% of the patients required the specific attention ofa psychiatrist; 4) 12% of the patients received psychotropic medication; 5) 6% ofthe patients required emergency consultation, and the evaluation was performed the same day as the referral; 6) 5% ofthe patients attempted suicide, none successfully; 7) 3% ofthe patients were hospitalized; and 8) 9% ofthe patients were considered to have problems not amenable to a time-limited treatment program and were referred to the community. Our cost experience has changed dramatically since the inception ofa full-time MHSD. In 1973, when mental health services were provided by paying outside consultants, the average cost per service approximated $1 .25 per member per month. Of this, 90 cents was for outpatient cane and 35 cents for inpatient care. Fifteen cents of the latter amount was for the treatment ofalcohol and drug abuse. With the development of the MHSD in 1974, outpatient costs dropped to 65 cents pen member pen month and inpatient costs to 15 cents pen member pen month. Since 1974 outpatient costs have climbed gradually, but inpatient costs have remained at a very low level: outpatient costs climbed to 71 cents pen member per month in 1975 and 77 cents pen member per month in 1976 while inpatient costs remained at 4 cents per member per month in both 1975 and 1976. After the development of the alcohol and substance abuse program in January 1976, outpatient expenses for the treatment of alcohol-related problems approximated 35 cents per member per month. As of the first 10 months of 1976, no patient had been admitted for inpatient care for alcoholism or substance abuse; all detoxification cases have been treated satisfactorily on an outpatient basis.
COMPARISON
PREPAID
OF
THE
FEE-FOR-SERVICE
AND
SECTORS
Since the beginning of our full-time program in February 1974, costs for mental health services have never exceeded $9.72 pen member pen year. These figures contrast with Reed’s findings for 1972 (5). He reported that the total cost for high-option Blue Cross and Blue Shield patients was $11.92 pen covered person per year, or 7.3% of total benefits. Similarly, Sharfstein
COMMUNICATIONS
and Magnas (6) reported that mental health benefits had plateaued to an average level of7.2% oftotal benefits for the period between 1972 and 1975. When such cost factors as data-processing equipment, marketing, space, and personnel are considered, 26 cents per member per month is added to our basic cost of8l cents per member per month. This results in a total cost of $1 .07 pen member per month, on $12.84 pen member per year. This $1.07 represents 4.4% of the total AHP cost of $24.10 per member pen month (our monthly average during the first 10 months of 1976). Reed (5) also noted that of the $1 I .92 charged to mental health conditions in the 1972 high-option Blue Cross and Blue Shield program, $6.62 (55.5%) of the benefits was for hospital care, excluding physicians’ changes. The remaining $5.30 (44.5%) of charges was for expenses incurred in services provided by physicians (both outpatient and inpatient), psychologists, and social workers. Reed concluded that almost twothirds
of the
total
benefits
were
for
the
care
of
hospital-
ized inpatients, and only one-third for outpatient cane. Furthermore, he cautioned that because patients paid 20% of outpatient charges after an initial $100 deductible, charges to Blue Cross and Blue Shield represented only 73% of the total charges. If we estimate that inflation has yielded an increase in medical cane cost of 30% in the 4 years since 1972 (7), we must add $3.58 to Reed’s figure of $11.92, yielding a cost of$l5.50 in 1976 (as compared with the 1976 AHP figure of $12.84). When we also consider that outpatients in the high-option Blue Cross and Blue Shield program paid a $100 deductible plus 20% of the cost beyond this deductible (compared with a $2.00 copayment per patient per visit in the AHP program), we have to conclude that the high-option indemnity program was more expensive than the AHP closedpanel program by at least 25%. Hospital admissions in the high-option indemnity program were 5.1 per 1,000 covered population; in the AHP they were .8 per 1,000. Average lengths of stay were 17.6 days in the former and 5.03 days in the latter. Most striking in the contrast between fee-for-service and HMO practices are their outpatient experiences. According to Reed (5), in 1972 outpatient cases numbered .6 per 1,000 population; the AHP outpatient refernal rate during 1975 and 1976 has approximated 35 per 1 ,000 enrollees. Further support of this higher use of outpatient services is provided by Fullerton and associates (4), who reported a doubling of the outpatient encounter rate in a clinic population within 1 year after the establishment of a comprehensive prepaid mental health program. In the fee-for-service sector both patient and provider have a financial incentive for hospitalization. In the high-option Blue Cross and Blue Shield program, 100% of hospital costs are covered but only 73% of outpatient costs are covered. After the initial deductible, there are few financial incentives to control the utilization of outpatient services in an indemnity pro341
BRIEF
gram. Thus, extrapolating from Sharfstein and Magnas’ data (6), 21% ofpatients consume more than twothirds of the total cost for outpatient treatment (8). The only financial barmier to treatment in the prepaid program is the $2.00 copayment for outpatient senvices.
COMMENT
The closed-panel system of our HMO provides an opportunity for collaboration among providers that is not as readily accessible in the indemnity on fee-forservice sector. Thus, at the AHP we have been able to organize crisis teams that serve both to minimize the need for hospitalization and to assume resources for treatment of patients following hospitalization. Furthermore, we collaborate with the primary medical providers, who are becoming aware ofour philosophy and our tactics in treating patients. Ultimately this close cooperation yields better control of disruptive patients. Although a psychiatrist in the fee-for-service sector may deal with a variety of constituents, his or hen primary constituent is the patient. The psychiatrist may feel some responsibility to third-party payers, but only in the long run does he share the risk of potential overutilization. In contrast, the HMO psychiatrist is acutely aware of budgeted resources. Patient treatment must occur within the constraints of finite financial and personnel resources. Thus, the prepaid psychiatrist must ask not only what the patient needs but what treatment the psychiatrist can commit that the prepaid plan is willing to provide. Initially the factor of cost accounting puts a considerable burden on the psychiatrist. Often feeling tainted by this awareness, the psychiatrist may respond by becoming overly rigid regarding policy interpretation or may react by becoming more permissive with patients. Furthermore, he or she must become accustomed to and begin to evaluate his or her role as part of a team
342
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COMMUNICATIONS
J Psychiatry
135:3,
March
1978
of mental health and medical providers. The psychiatnist’s skills as a consultant and as an educator will be tested, as well as his or her skills as a therapist. He or she must be able to meet the challenge of what can be done within a limited period of time and with limited financial resources. In balance, we believe that prepaid mental health care provides a viable role for the contemporary psychiatnist, given the personality attributes that would permit him on hen to practice as part ofa larger team. Prepaid psychiatric practice offers several significant contrasts to practice in the fee-for-service sector. First, a greaten emphasis is placed on short-term treatment. Second, prepaid psychiatric practice challenges the psychiatrist to mobilize resources in an outpatient setting to prevent unnecessary and costly hospitalizations. Third, prepaid psychiatric practice demands close participation and cooperation with the broader mental health and medical team. REFERENCES I. Goldensohn SS, Fink R, Shapiro S: Referral, utilization, staffing patterns of a mental health service in a prepaid practice
program
in New
York.
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of the
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and
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Blue
Am J Am Price
costs. (ltr to