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April 12, 2002

Managed care doesn’t skimp on referrals to mental health specialists

Managed care controls do not appear to reduce access to specialized mental health care among depressive patients in primary care clinics, according to researchers at the University of Washington.

The finding was a surprise to researchers, given the common belief that managed care limits access to specialists in order to control costs.

“Quite frankly, we were surprised the evidence of reduced access was relatively weak,” says Dr. David Grembowski, professor of health services in the UW School of Public Health and Community Medicine. The study is published in the April issue of Journal of General Internal Medicine.

To conduct the study, researchers had to tackle the growing complexity of managed health care. They had to consider different permutations of managed care, fee for service, and alphabet soups of HMO vs. non-HMO vs. PPO. The study became increasingly complex, as researchers had to sort through hundreds of different health plans. And they also had to consider how medical offices managed their care, and how doctors were paid.

“No other study is comparable,” says Dr. Carolyn Clancy, director of the Center for Outcomes and Effectiveness Research at the federal Agency for Health Care Policy and Research, which funded the research. “The study design is unprecedented because the investigators identified the complexities of managed care plans confronting most primary care clinicians today. The research team recognized that primary care physicians routinely contract with multiple managed care arrangements. In addition, they also were cognizant that the decision to refer an individual patient to a specialist is often not straightforward.”

The study found that the people surveyed six months later appeared to have slightly better outcomes in managed care offices, although people reported on surveys that they were less happy with their care. The outcomes may have been better because clinics that practice managed care tend to be large; and larger clinics are likely to have clear guidelines for mental health care, and may have mental health professionals on site.

However, the study did find that people in managed care systems were less likely to be referred to a psychiatrist. That’s of some concern, says one of the co-authors, Dr. Wayne Katon, UW professor of psychiatry and behavioral sciences.

“You want to make sure that you are matching people to the proper level of care that’s needed. You want to match the patient to the provider most appropriate for them,” he says.

The sample in this study was 942 individuals with depressive symptoms, found from among more than 17,000 people screened in the offices of 261 primary care doctors in Seattle. The researchers interviewed and followed a total of 2,850 people as part of this and other studies. Those people had a total of 189 different health plans. But each of those plans themselves had different benefits, depending on a patient’s employer or other source of health insurance. So for the 942 people, the researchers had to calculate the “managedness” of more than 750 plans and benefit packages.

There were two problem areas. One is that the study found reduced referrals to psychiatrists in health plans that were more “managed.” Many of the managed health care plans have fewer psychiatrists among their lists of preferred providers, which may account for this finding. Also, some plans have “mental health carveouts,” in which a separate entity provides mental health services. “Those plans create an artificial separation between physical health and mental health,” Katon says.

The study also found that doctors who got more money for referring less to specialists did indeed refer less, particularly for low-income patients.

“That’s particularly worrisome because the low-income patients tend to have more severe depressive symptoms. If there is any group that you would want to refer for, it’s those who are more severely depressed,” Grembowski says. “There’s been previous evidence that HMOs may do fine for healthy patients – but how do vulnerable patients fare? There may be cause for concern.”

Some doctors were paid by a “financial withhold” system. (A financial withhold is when an insurance company or other payor withholds a certain amount of money that it would otherwise pay a doctor. If a doctor’s referrals are not “excessive,” as defined by the health plan, then the doctor receives the withheld funds.)

“A financial withhold clearly creates an incentive for a physician to be cost-conscious when referring,” Grembowski says.

However, there was not a clear harm from this practice. The findings showed that people who did not get the referral still sought out a mental health professional; they were able to find help anyway. “Patients may have been going out on their own to see a specialist,” Grembowski says.

Physicians who receive a productivity bonus based on the number of patients they see were actually more likely to refer patients to a mental health specialist. That may be because these physicians must see a large number of patients in a given day, and may be encouraged to refer patients who would take up a lot of time to a specialist. “Patients with depression take longer than many other patients, because there is more talk involved,” Grembowski says.

So how can the average consumer tell how managed his plan or her plan will be? Patients wondering about what their plan allows may have to do their own research. Katon, who sees patients, says that many often have no idea what their plan covers.

“There is a lot of confusion out there. Patients usually have to go home and do homework, and that’s not always easy for someone with the symptoms of depression. The system is set up to be difficult, and there is a risk that people will become discouraged and stop trying,” Katon says.