Patient satisfaction with an injection device for multiple sclerosis treatment.

OBJECTIVES: To develop a measure of treatment satisfaction assessing attributes specific to injected interferon-beta-1a (IFN-beta-1a) for multiple sclerosis (MS), and to test pain and instrument sensitivity to change among patients changing injection devices. MATERIALS AND METHODS: The MS Treatment Concerns Questionnaire (MSTCQ) was developed and tested with pain assessments before and 3 months after patients changed devices from Rebiject to Rebiject II. RESULTS: The MSTCQ was organized with two domains: Injection System Satisfaction and Side Effects (three subscales: Injection Site Reactions, Global Satisfaction, and Flu-Like Symptoms). Significant improvements (P = 0.002 to P < 0.001) occurred with the new injection device in all MSTCQ subscales (except Flu-Like Symptoms), and all pain measures (P < 0.0001). Clinically meaningful improvement was demonstrated in all scales, except Flu-Like Symptoms, by effect sizes (0.23-0.59). CONCLUSIONS: These statistically significant and clinically meaningful improvements in MSTCQ and pain measures show the value of technologically advanced devices in domains of concern to patients.

The relationship between treatment access and spending in a managed behavioral health organization.

OBJECTIVE: This study replicated an earlier study that showed a linear relationship between level of treatment access and behavioral health spending. The study reported here examined whether this relationship varies by important characteristics of behavioral health plans. METHODS: Access rates and total spending over a five- to seven-year period were computed for 30 behavioral health plans. Regression analysis was used to estimate the relationship between access and spending and to examine whether it varied with the characteristics of benefit plans. RESULTS: A linear relationship was found between level of treatment access and behavioral health spending. However, the relationship closely paralleled that found in the earlier study only for benefit plans with an employee assistance program linked to the managed behavioral health organization and for plans that do not allow the use of out-of-network providers. CONCLUSIONS: The results of this study replicate those of the earlier study in showing a linear relationship between access and spending, but they suggest that the magnitude of this relationship may vary according to key plan characteristics.

Analysis of a managed psychiatric disability program.

The cost of mental illness to employers has been well documented; however, efforts to effectively reduce the costs of psychiatric disability are adversely affected by the fragmentation of health care services. This report is a case study of a program in which a managed behavioral health care organization managed the psychiatric disability of a telecommunications company. Compared with a non-random cohort of claimants not managed under the pilot, the duration of disability was reduced by 23% (17.1 days). Patient and provider satisfaction with the program was high. This study illustrates the potential for effectively reducing the cost of psychiatric disability and the challenges in coordinating health care.

The impact of prior authorization on outpatient utilization in managed behavioral health plans.

This study examines how preauthorization affects outpatient behavioral health utilization under managed care by comparing plans with similar benefits, but differing in the number of visits authorized. The authors compare plans primarily authorizing in increments of 5 visits to plans authorizing in increments of 10 visits. They analyze the likelihood of terminating outpatient service between the two groups using conditional logistic regression. Results suggest that patients whose treatment is authorized in increments of 5 sessions are nearly 3 times more likely to terminate treatment at exactly the fifth visit than if their treatment is authorized in increments of 10 sessions conditional on being in treatment until the 5th visit. The likelihood of termination peaks in both the 5- and 10-session authorization at the 10th visit, but the difference is not statistically significant. The authorization effect differs by provider type and is weaker among psychiatrists than among nonphysician providers.

Patients' and providers' perceptions of outpatient treatment termination in a managed behavioral health organization.

OBJECTIVE: A common complaint about managed care is that treatment decisions of patients and providers are frequently altered by concurrent review of ongoing outpatient treatment. The objective of this study was to examine this perception from the perspectives of patients and providers. METHODS: A total of 190 patients and their providers were surveyed about the reason that outpatient treatment was terminated. The sample was randomly drawn from completed outpatient treatment episodes of a large national managed behavioral health organization. RESULTS: In more than three-quarters of the cases, outpatient treatment ended because patients and providers agreed that treatment goals were partially or completely met. Only 5 percent of patients and 3 percent of providers said that treatment ended because the managed care organization denied ongoing treatment. Agreement between patient-provider pairs was generally poor regarding the perceived reason for termination, except when termination was attributed to concurrent review by the managed behavioral health organization. CONCLUSIONS: In this study of a single large managed behavioral health organization, outpatient treatment was most likely to end based on the decisions of patients and providers rather than utilization review decisions.

Economic consequences of comorbid depression, anxiety, and allergic rhinitis.

The present study extends prior work on the association between allergic rhinitis (AR) and common mental disorders by testing three related hypotheses: 1) that AR is associated with increased rates of depression and anxiety disorders in a large insured population, 2) comorbid AR, depression, and anxiety are associated with increased health and mental health expenditures, and 3) allergy treatment moderates the association between increased expenditures and comorbid AR, depression, and anxiety. Data are from MARKETSCAN, a large health care claims database of over 600,000 privately insured persons. Results indicate that AR is associated with higher rates of depression and anxiety disorder. Outpatient health care expenditures were increased by an average annual amount of $207 when AR and anxiety disorder were comorbid and $363 when AR and depression were comorbid. Finally, prescription treatment of AR moderated the increased expenditures associated with comorbidity.

Does managing behavioral health care services increase the cost of providing medical care?

This study examined the possibility that managing behavioral health care services achieves savings by cost shifting--by denying care or impeding access to care--and in that way encouraging patients to seek needed behavioral health care in the medical care system. In 1993, a large industrial company carved out employee behavioral health care from its unmanaged, indemnity medical care benefits and offered employees an enhanced benefit package through a managed behavioral health care company. This study compared the use and cost of behavioral health care and medical care services for two years before the carve-out and for three years afterward. The rate of behavioral health care usage remained the same or increased after the carve-out, while the cost of providing the care decreased. Controlling for trends that began before the inception of managed behavioral health, medical care costs decreased for those using behavioral health care services. No evidence supporting cost shifting was found.

More evidence for the insurability of managed behavioral health care.

Debate continues about the cost and use of mental health services under managed care, as legislators consider various "parity" bills. This descriptive research replicates, broadens, and expands previously published case studies of single employers' data on cost and treatment prevalence in a large, diverse, national sample whose varied point-of-service benefits were provided by thirty employers representing multiple industries. Of those covered, 59,005 received treatment over the seven years studied. Of particular note is the pattern of increased use, increased care within the managed behavioral health organization network, and long-term cost reductions.

Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression.

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

Disruptive behavior and the determinants of costs in the public mental health system.

Efforts to increase the cost-effectiveness of public mental health systems are hindered by inadequate information about the determinants of use and cost. This paper reviews empirical research and theory suggesting that costs in the public health system are affected more by the disruptive behavior of persons with severe mental illness than by their age, sex, race, and diagnosis, which have been the focus of most economic studies. The author proposes modifications of traditional theories of health service use to explicitly account for the role of disruptive behavior in determining public mental health system costs. He describes a help-seeking pathway in the public mental health system in which the decision to seek treatment is initiated not by the mentally ill person but by others affected by the person's disruptive behavior. This "other-determined" pathway into treatment is contrasted with the self-determined pathway in which an individual with distressing symptoms makes a rational choice to seek help. Empirical research consistent with the other-determined perspective will help target clinical interventions and system reforms to the factors responsible for high-cost mental health care and will improve the ability to predict resource use from observable clinical characteristics of consumers.

The association between body mass and health care expenditures.

With several studies estimating the health care costs attributable to obesity-related medical conditions, the economic consequences of being overweight are beginning to come into focus. The present study complements this growing body of literature by directly estimating health care costs across a broad range of body mass index values. Data were obtained from the 1987 National Medical Expenditure Survey (NMES) public use data tapes and retrospective analyses conducted on NMES Household Survey data only. The analyses included a total of 16,217 individuals between the ages of 18 and 65. Four classes of health care utilization and expenditures were derived using the NMES data: (1) use of any health care service and total health care expenditures, (2) use of inpatient services and inpatient expenditures, (3) use of outpatient services and outpatient expenditures, and (4) use of prescription medication and medication expenditures. Estimates based on our findings suggested strong relationships between body mass and the likelihood of using health care services and between body mass and average annual health care expenditures for both men and women. Increased body mass was associated with increased expenditures. However, this association was greater among males than among females and did not hold for individuals in the lowest body mass category. Ideal body mass was associated with 6.3% to 36.1% lower annual health care expenditures among females and 3.6% to 18.2% lower health care expenditures among males. The results of this set of analyses suggest that health care expenditures increase as weight deviates from the ideal-that is, health care expenditures among both underweight and overweight individuals in the United States were increased in relation to ideal weight. Separate analyses including weight-related diseases such as diabetes and hypertension indicated that body mass increased health care expenditures largely by increasing the risk for these costly chronic medical conditions.

An instrument for measurement of outcomes of care for schizophrenia. Issues in development and implementation.

To advance effectiveness research in mental health, we need common, standardized, validated instruments that can be used easily in routine practice settings. The Schizophrenia Outcomes Module is a relatively brief, comprehensive instrument for monitoring and assessing the outcomes of treatment for schizophrenia in clinical care settings. The module was developed with the guidance of a multiinstitutional, multidisciplinary expert panel; the clinical and theoretical considerations that framed the expert panel's deliberations and determined the module's content and characteristics are described. Initial field testing of the instrument involved longitudinal observation of 100 individuals with schizophrenia over a 6-month period. To our knowledge, it is the only brief and easily administered instrument that encompasses the four major outcome domains defined by the National Institute of Mental Health's Plan for Research on the Severely Mentally Ill. As such, it is a promising tool for effectiveness research in schizophrenia.

Awareness of illness in schizophrenia and outpatient treatment adherence.

We present a brief measure of awareness of illness in schizophrenia and test whether awareness is related to perceived need for and adherence to outpatient psychiatric treatment. A prospective design assessed treatment adherence, awareness of the signs and symptoms of schizophrenia, symptoms, neurocognitive status, and substance abuse at baseline and 6-month follow-up in 89 persons with schizophrenia. Results indicate that persons with greater awareness perceived greater need for outpatient treatment and evidenced better adherence to outpatient treatment when adherence and awareness were measured concurrently. Awareness was not related to adherence at 6-month follow-up. In addition, neurocognitive impairment was associated with lower overall adherence to treatment when reported by collaterals at baseline and 6-month follow-up. Neurocognitive impairment was, however, associated with higher self-reported adherence to medication, which suggests that neurocognitive status may bias adherence reporting in persons with schizophrenia.

Substance abuse, community service use, and symptom severity of urban and rural residents with schizoprhenia.

OBJECTIVE: This study examined the relationships of substance abuse, use of community-based services, and symptom severity among rural and urban residents with schizophrenia in the six months after discharge from short-term inpatient care. METHODS: At baseline and six-month follow-up, symptom severity of 139 subjects was assessed using the Brief Psychiatric Rating Scale (BPRS), and substance abuse status was determined using the Structured Clinical Interview for DSM-III-R (SCID). Subjects' reports of mental health service use were confirmed by record review. RESULTS: Although, on average, BPRS scores indicated symptom improvement between baseline and follow-up, symptoms worsened for 27 percent of subjects. Multivariate analysis, adjusted for baseline symptom severity, indicated poorer outcomes for rural residents, substance abusers, and subjects who did not use community services. Symptoms of rural substance abusers who used no community services were worse at follow-up than those of any other subgroup. Nearly half of all subjects had less than monthly contact with community services. The greater likelihood of symptom worsening among rural residents was attributed to their less frequent use of community services. CONCLUSIONS: The findings reinforce the importance of ensuring involvement in community-based services for individuals with comorbid schizophrenia and substance use disorders. Promotion of service use by persons with a dual diagnosis may be particularly critical to the well-being of rural residents with schizophrenia.

Medication noncompliance and substance abuse among patients with schizophrenia.

OBJECTIVE: The study examined the effect of medication noncompliance and substance abuse on symptoms of schizophrenia. METHODS: Short-term inpatients with a diagnosis of schizophrenia were enrolled in a longitudinal outcomes study and continued to receive standard care after discharge. At baseline and six-month follow-up, Brief Psychiatric Rating Scale (BPRS) scores and data on subjects' reported medication compliance, drug and alcohol abuse, usual living arrangements, and observed side effects were obtained. The number of outpatient contacts during the follow-up period was obtained from medical records. Relationships between the dependent variables-medication noncompliance and follow-up BPRS scores-and the independent variables were analyzed using logistic and linear regression models. RESULTS: Medication noncompliance was significantly associated with substance abuse. Subjects who abused substances, had no outpatient contact, and were noncompliant with medication had significantly greater symptom severity than other groups. CONCLUSIONS: Substance abuse is strongly associated with medication noncompliance among patients with schizophrenia. The combination of substance abuse, medication noncompliance, and lack of outpatient contact appears to define a particularly high-risk group.

Symptom heterogeneity in comorbid alcohol disorder.

The heterogeneity of signs and symptoms of alcohol disorder was examined in a community sample of 1,955 persons with either alcohol disorder alone or alcohol disorder plus one of four categories of major mental disorder (antisocial personality disorder, schizophrenia, affective disorder, anxiety disorder). When all diagnostic categories were combined, persons with comorbid mental and alcohol disorders showed evidence of more severe alcohol-related symptoms than did persons with alcohol disorder alone. Distinct symptom patterns distinguished the four diagnostic groups, reflecting heterogeneity in the manifestation of comorbid alcohol disorder. Most notably, comorbid antisocial personality disorder and schizophrenia were associated with higher levels of alcohol consumption and more severe social consequences of alcohol use. These findings substantiate the need for development of specialized dual diagnosis programs and suggest that additional specialization may be required to address diagnostic group differences in the characteristics of comorbid alcohol disorder.