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.
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