New directions in research on assertive community treatment.

Evaluation of assertive community treatment programs has demonstrated that they are highly effective in reducing the need for psychiatric hospitalization of chronic mentally ill patients. However, the programs also tend to cost more than traditional outpatient care, and their impact on other areas of patient functioning is not clear. The authors believe more rigorous studies of the programs are needed before policymakers can properly evaluate their role in the overall mix of services. Future studies should extend previous research by comparing the programs to current state-of-the-art treatment in community mental health centers or county mental health programs; assessing the total system costs of assertive community treatment programs, as well as the amount of cost shifting by payers; analyzing outcomes of clients in mature programs over longer time periods; standardizing the measurement of various client outcomes; and determining the impact of individual program elements--alone and in combination--on different subgroups of clients.

Hospitalization for psychiatric illness under Medicare, 1985.

National and state-level data on Medicare-covered hospital discharges after treatment for psychiatric illness in 1985 were analyzed to determine the distribution of cases among various types of psychiatric and general hospitals. In most states, 80 to 90 percent of Medicare patients with psychiatric conditions received care in a setting that provided specialized treatment for psychiatric illness. However, the distribution of discharges among public and private psychiatric hospitals and general hospitals with psychiatric units varied substantially among states. Between 1984, the first year of Medicare's prospective payment system, and 1985, the number of discharges decreased overall, and a shift toward treatment in specialized psychiatric facilities and toward settings exempt from the prospective payment system was apparent.

State strategies to restructure psychiatric hospitals: a selective review.

All state mental health authorities are restructuring the role of their state psychiatric systems as part of the overall system of specialty psychiatric services. These efforts include shifting funds to community programs, changing the hospital from both a short- and long-term facility to one or the other, and giving community programs more administrative and budgetary authority over the hospitals. This paper presents case studies of five such efforts, selected to illustrate the range of change and the mechanisms for achieving it. Inferences are drawn from these studies and directions for research are suggested.

Analysis of the effect of disproportionately large share of low-income patients on psychiatric costs in general hospitals.

This study focuses on the disproportionate share payment adjustment of the Medicare Prospective Payment System and examines the relationship between share of low-income patients and the cost of inpatient psychiatric care. All general hospitals without distinct psychiatric units that treated more than 20 Medicare psychiatric patients in general medical-surgical beds are included in the cost analysis. The difference between official adjustment factors and the estimates of this analysis suggests that in 16% of the large urban disproportionate share hospitals poverty psychiatric cases are systematically underpaid.

Use of specialty psychiatric settings in constructing DRGs.

Characteristics of a psychiatric setting, such as staffing intensity and scope of services, are examined to see if they contribute to explaining variation in length of stay over that explained by commonly available patient descriptors. For short-stay admissions (less than 31 days), only a small improvement in predictive ability was found. Implications for prospective payment systems are discussed.

Psychiatry under prospective payment: experience in the first year.

The authors present data on changes in resource use by Medicare psychiatric patients in general hospitals after the introduction of the prospective payment system in 1984. Length of stay and charges per discharge during fiscal year 1984 fell 13.8% and 15.9%, respectively, after the new system began, even though 31.8% of the discharges for Medicare psychiatric cases were from exempt psychiatric units. The decrease in length of stay was considerably larger (23.2%) in hospitals with no psychiatric units, which were not exempt from prospective payment.

The use of ambulatory services by persons with and without phobia.

The delivery of ambulatory mental health and general health services to persons with phobias (unweighted n = 1,689) and without phobias during a 6-month period are examined. The phobics were part of a larger study of 18,572 subjects, drawn as a representative sample of the population in five locations, as part of the Epidemiologic Catchment Area Program (ECA). Among phobic conditions, agoraphobia most often leads to use of services related to emotional problems, especially in the specialty mental health sector. There were no significant differences between male and female subjects in their use of the various sectors for a mental health reason. The highest age group of agoraphobics that used health services most often was 25-44 years old, and the group that used them least often was 65 years and older. Agoraphobics with four or more symptoms of panic use services in higher proportions than agoraphobics with zero to three panic symptoms. The authors observe that a very large proportion of phobics report seeking no help from any source.

Mental health services system research: the National Institute of Mental Health program.

There is a critical need for research to examine the changing mental health services system, to evaluate major innovations in the provision of mental health treatment, and to remove existing barriers to comprehensive and cost-effective care. To achieve these aims, collaboration is needed among government agencies, mental health services programs, academic institutions, and the private sector. The National Institute of Mental Health supports research and research training on the mental health services system primarily through the Division of Biometry and Applied Sciences. This article focuses on the division's three priority research areas of the mental health services system: the provision of mental health care in the primary care sector, the organization and delivery of care for the chronically mentally ill, and financing and reimbursement of care. The various mechanisms of research support are also highlighted.

The severely mentally ill in general hospital psychiatric units.

Analysis of data from the NIMH Survey of Discharges from Non-Federal General Hospitals found that severely mentally ill patients (those with schizophrenia, other psychoses, paranoia, and major affective disorders) became an increasingly larger proportion of general hospital discharges between 1970 and 1980, with more change observed between 1975 and 1980. This seems to confirm that general hospital care is replacing at least some of the care previously provided in State mental hospitals. There has been an increase in beds in nongovernment-owned general hospitals and a decrease in beds in state hospitals. In addition, while discharge referrals from government general hospitals for severe patients were made predominantly to state hospitals in 1970, in 1980 this was rarely the case.

High users of outpatient mental health services, II: Implications for practice and policy.

Four assumptions underlie the stereotyped view of use of outpatient mental health services: 1) all use is alike, 2) any use leads to high use, 3) all high use is discretionary, and 4) insurance encourages excessive use. The authors refute the first three assumptions and suggest that different types of treatment episodes vary in their responsiveness to price. Diagnosis appears to be a poor indicator of inpatient needs; some coverage limits outpatient benefits according to type of treatment. The authors favor a combination of pricing strategies, as well as case management and clinical review for high users, which would not impede initial treatment but would limit excessive use of mental health services.

High users of outpatient mental health services, I: Definition and characteristics.

Mental health coverage generally limits benefits for high use, which is assumed to be discretionary. The authors present data from the National Medical Care Utilization and Expenditure Survey. Of the individuals who made mental health outpatient visits in 1980, 9.4% made 25 or more visits and accounted for 50% of mental health visits and expenditures. These high users were compared with low users and with high users of other health care. One-third of the mental health high users were highly disabled and had multiple medical disorders. The authors point out the heterogeneity of this population and suggest that psychiatric benefits be differentiated according to patients' needs and services offered.

Technical and allocative efficiency in production of outpatient mental health clinic services.

This paper presents an analysis of production of ambulatory mental health services in free standing outpatient clinics. The study empirically addresses several issues including: the nature of returns to scale, the impact of differing organizational forms on the volume of service produced and the efficiency of staffing patterns used by psychiatric clinics. An appraisal of two popular production functions is offered based on predictive performance. The results suggest the existence of decreasing returns to scale; input hiring decisions that depart from cost minimization; and the potential important of a decentralized clinic organization for expansion of access to mental health services.

Validity of Medicaid household respondent reporting of ambulatory visits for mental disorders.

Comparison with administrative records or "best estimate file" enables an evaluation of the accuracy of household reports of mental health use in the four-State Medicaid Household Survey conducted as part of the National Medical Care Utilization and Expenditure Survey. Underreporting of probability of ambulatory mental health use ranged from 14 to 24% compared to 5 to 7% for ambulatory health visits; household estimates of number of mental health visits seemed to be more accurate than administrative records. Household reporting of provider type seemed to be very accurate for psychiatrist visits, but there seemed to be a tendency to report psychologist visits as psychiatrist visits.

The effect of Medicaid on access to ambulatory mental health care for the poor and near-poor under 65.

Analysis of the National Medical Care Utilization and Expenditure Survey indicates that the poor/near-poor with continuous Medicaid coverage had almost double the probability of use of ambulatory mental health care compared with the poor/near-poor not enrolled in Medicaid. The higher probability of use reflects the impact of increased financial accessibility to needed mental health services and may also be influenced by an associated demand for social services provided by organized mental health settings in addition to clinical services. Intensity of use per user was not significantly different between Medicaid- and non-Medicaid-enrolled poor/near-poor, but the percent paid out of pocket was substantially lower for those continuously in Medicaid.

Estimating the probability and level of ambulatory mental health services use.

Analysis of the National Medical Care Utilization and Expenditure Survey for persons with positive out-of-pocket expenses for one or more ambulatory mental health visits indicates that demand for such visits is responsive to price, and considerably more so than demand for health visits. Income, education, and insurance coverage interact in predicting demand, and price elasticity varies across income groups.

Prospective payment and psychiatric discharges from general hospitals with and without psychiatric units.

For psychiatric patients treated in general hospitals, the prospective payment system does not differentiate between patients treated in medical-surgical wards and patients treated in psychiatric units. In particular, the system uses a single length-of-stay norm for both kinds of patients, even though psychiatric patients in medical-surgical units have shorter stays. The authors document major differences in length of stay and hospital charges for both groups of patients in relation to selected patient and hospital characteristics. They conclude that the current reimbursement procedures systematically overpay for stays in nonpsychiatric units and underpay for stays in psychiatric units, and they suggest mechanisms for partly reducing such inequities.