Privatization of psychiatric services.

The authors provide an overview of privatization, a major trend in mental health policy, focusing in particular on the reasons for and consequences of substantial growth and change in ownership of private psychiatric hospitals; the proportion of all nonfederal psychiatric inpatient beds in private facilities has increased from less than 10% in 1970 to 35% today. It is estimated that between 1970 and 1986, the proportion of total nonfederal psychiatric inpatient beds in the United States that were under corporate for-profit auspices increased from about 1% to 15%. The authors distinguish and examine several aspects of privatization and assess the implications of these changes for psychiatry and for public policy and research.

Psychiatry and the resource-based relative value scale.

Attention to reform of reimbursement for psychiatric inpatient services largely focuses on the use of prospective payment systems, e.g., payment based on diagnosis-related groups (DGRs), for hospitals. Recently, there also has been interest in proposals for altering physician reimbursement (inpatient and outpatient) by using physician DRGs, capitation models, or relative value scales instead of the charge-based, fee-for-service model. The authors review the resource-based relative value scale (RBRVS) as an option for psychiatry. The RBRVS uses the setting, the time spent, the difficulty in treating the patient, the training, and the psychiatrist's role to determine reimbursement rates.

Managed care constraints on psychiatrists' hospital practices: bargaining power and professional autonomy.

OBJECTIVE: The increasing involvement of insurers and hospitals in monitoring patient care is encroaching on the psychiatrist's autonomy in making clinical decisions. This study examined the prevalence of constraints on psychiatric inpatient practices, as well as how characteristics of psychiatrists affect the type and the degree of these external pressures. METHOD: About 2,500 psychiatrists with active hospital affiliations were surveyed by mail, as a subset of APA's 1988 national survey of psychiatrists. They were questioned about whether the hospital or insurers had pressured them to change their inpatient practices or had attempted to discourage admission of certain types of patients. Characteristics of the psychiatrists' background, available from the main survey, were used as independent variables in a set of regression models, with frequency of different constraints as the dependent variables. RESULTS: More than three quarters of those surveyed reported pressure from insurers for early discharge; nearly two-thirds said hospitals limited length of stay; and about half had been discouraged from admitting severely ill patients, the uninsured, or Medicaid recipients. Characteristics of psychiatrists, such as length of time in practice, income, sex, and medical school education outside the United States, were associated with the prevalence of external pressures. CONCLUSIONS: Constraints on psychiatrists' practices are widespread. Their ability to resist pressures depends on their bargaining power, which seems to be lowest for those who have relatively little experience, who are female, or who have gone to medical school outside the United States. Psychiatrists appear to be willing to trade off more constraints for higher incomes. Severely ill patients and those with little or no insurance are more likely than others to be affected by these limits on psychiatrists' autonomy.

Measuring the determinants of work values for psychiatrists' services in the resource-based relative value scale study.

OBJECTIVE: As part of the Harvard resource-based relative value scale study, the authors investigated how well the codes in the Physician's Current Procedural Terminology, 4th edition, or CPT-4, match psychiatric services to the work involved in evaluating and managing patients and how patient care characteristics affect different levels of psychiatric work. METHOD: A random sample of over 200 psychiatrists and subspecialists was asked to use 68 typical clinical examples or vignettes to evaluate services described by CPT codes. Data were analyzed by multivariate statistical methods. RESULTS: The survey showed that the existing coding system does not adequately describe the work that psychiatrists do. Within a single code (e.g., 90844, individual medical psychotherapy), there was wide (more than twofold) variation in the estimates, from multiple measurements based on different vignettes, of the amount of work represented. Estimates of work values varied significantly according to treatment setting and patient characteristics: psychiatric services in the hospital showed an average work value 25% greater than that for office services; treating new patients involved 18% more effort than treating established patients; and treating patients described as at risk of harming self or others increased the psychiatrists' work effort by 36%. CONCLUSIONS: Revisions in coding evaluation and management services in the new Medicare fee schedule for psychiatric services should be further refined and then implemented. These revisions would bring the coding system into line with psychiatric practice, making it a better way of accounting for the relative work involved in treating patients of varying difficulty.

A national study of psychiatric hospital care.

BACKGROUND: The delivery system for psychiatric inpatient services in the United States has changed dramatically over the past 30 years, undergoing a marked privatization. METHOD: To assess the effect of changes in ownership and types of inpatient settings on the structure of the mental health services system, the authors surveyed a national sample of nonfederal mental health facilities in 1988. RESULTS: Comparing their data to those of earlier surveys, they found that a decline in the number of patients per staff occurred in most settings over the last decade, suggesting that this aspect of quality of care may have improved. They observed important ownership-related differences in 1988 in diagnostic mix (e.g., more schizophrenia treated in public facilities than in private ones) and in payer source (e.g., more third-party revenues in public facilities than occurred in the past). CONCLUSIONS: There was a significant interaction between ownership form and type of facility, suggesting that the type of inpatient setting, ownership, and the relation between the two should be considered in assessing the impact of privatization on the accessibility of health care available for the mentally ill. The authors found that the increase in private psychiatric hospitals has widened the availability and choice of treatment facilities for those with private funding sources (especially children and adolescents) but has not had a similar effect in increasing sources of care for the seriously mentally ill dependent upon public financing.

Variation in ECT use in the United States.

OBJECTIVE: The authors measured the variation in ECT utilization rates across 317 metropolitan statistical areas of the United States and determined to what degree this variation is associated with health care system characteristics, demographic factors, and the stringency of state regulation of ECT. METHOD: Data from APA's 1988-1989 Professional Activities Survey were used to estimate ECT utilization rates for the metropolitan statistical areas. Multiple regression analysis was used to determine the relative influence of provider, demographic, and regulatory factors on variation in ECT use across areas. RESULTS: Among the psychiatrists surveyed, 17,729 reported treating 4,398 patients with ECT during the study period. No ECT use was reported in 115 metropolitan statistical areas. Among the remaining 202 metropolitan statistical areas, annual ECT use varied from 0.4 to 81.2 patients per 10,000 population. The strongest predictors of variation in ECT use across metropolitan statistical areas were the number of psychiatrists, number of primary care physicians, number of private hospital beds per capita, and stringency of state regulation of ECT. CONCLUSIONS: Rates of ECT use were highly variable, higher than for most medical and surgical procedures. In some urban areas, access to ECT appears limited. Predictors of variation in ECT rates have implications for expanding access to the procedure. The extent of variation suggests psychiatrists continue to lack consensus regarding the use of ECT. Better data on the effectiveness of psychiatric treatments may lead to a broader professional consensus and may narrow variations in clinical practices.

Characteristics of psychiatrists who perform ECT.

OBJECTIVE: Use of ECT is highly variable, and previous study has linked its availability to the geographic concentration of psychiatrists. However, less than 8% of all U.S. psychiatrists provide ECT. The authors analyzed the characteristics of psychiatrists who use ECT to understand more fully the variation in its use and how changes in the psychiatric workforce may affect its availability. METHOD: Data from the 1988-1989 Professional Activities Survey were examined to investigate the influence of demographic, training, clinical practice, and geographic characteristics on whether psychiatrists use ECT. RESULTS: Psychiatrists who provided ECT were more likely to be male, to have graduated from a medical school outside the United States, and to have been trained in the 1960s or 1980s rather than the 1970s. They were more likely to provide medications than psychotherapy, to practice at private rather than state and county public hospitals, to treat patients with affective and organic disorders, and to practice in a county containing an academic medical center. CONCLUSIONS: Demographic and training characteristics significantly influence whether a psychiatrist uses ECT. Opposing trends in the U.S. psychiatric workforce could affect the availability of the procedure. Expanding training opportunities for ECT and making education, training, and testing more consistent nationwide could improve clinicians' consensus about ECT and narrow variation in its use.

A national study of psychiatrists' professional activities.

OBJECTIVE AND METHOD: A mail survey was conducted in 1988-1989 to study the professional activities of U.S. psychiatrists. Data from the 19,431 active respondents are reported. RESULTS: Nineteen percent of the psychiatrists were women, an increase from the 17% reported in 1982. The median age of the respondents was 50 years. Nearly one-third of the respondents expressed interest in each of the following areas of subspecialization: adolescent psychiatry, substance abuse, geriatrics, and consultation-liaison psychiatry. More than one-fifth reported formal fellowship training in child/adolescent psychiatry. The psychiatrists worked an average of 48 hours per week--two-thirds in direct patient care--in an average of 2.3 different settings. The proportion of psychiatrists reporting private practice as their primary work setting showed a marked decline from 53% in 1982 to 45% in 1988. There was an increase from 4% in 1982 to 11% in 1988 in those whose primary work setting was a private psychiatric hospital. The typical caseload was over 60 patients, with roughly half that number seen each week. For inpatients treated, the two most common diagnoses were affective disorders and schizophrenic disorders. In a typical week psychiatrists treated about one-half of their outpatients with individual psychotherapy; three-fifths of these were also treated with medications. The average net income for psychiatrists working 35 hours or more per week was $99,850 for men and $73,174 for women. CONCLUSIONS: Major trends evident from this study are subspecialization, medicalization, privatization, feminization, and organizational diversification.

Use of electroconvulsive therapy in the Medicare population between 1987 and 1992.

OBJECTIVE: Use of electroconvulsive therapy (ECT) in the Medicare population was examined to document trends and variations in the rate of use, expenditures, and patterns of treatment. METHODS: Medicare part B enrollment and claims data were used for a 5 percent nationally representative sample of Medicare beneficiaries for calendar years 1987 through 1992. Descriptive and multivariate analyses were performed. RESULTS: Weighted results showed that nationally the number of Medicare beneficiaries treated with ECT increased from 12,000 in 1987 to 15,560 in 1992. The rate of ECT use per 10,000 Medicare beneficiaries also increased from 4.2 to 5.1. Increases in use occurred among women, whites, and the disabled population (under age 65). Males, nonwhites, and the elderly did not share in the increase. Utilization and expenditure data showed an increase in outpatient ECT and a decrease in inpatient use between 1987 and 1992. The share of Medicare part B ECT expenditures in the outpatient setting increased steadily, from 7 percent in 1987 to 16 percent in 1992. Patients averaged eight ECT treatments, ranging from 6.7 in the West to 8.3 in the Northeast. CONCLUSIONS: The findings document that after a long period of declining use in the United States, ECT use in the Medicare population increased between 1987 and 1992. The analysis also documents a shift toward increasing use of outpatient ECT.

Diagnoses of patients treated with ECT: a comparison of evidence-based standards with reported use.

OBJECTIVE: This study assessed the extent to which patients treated with electroconvulsive therapy (ECT) had diagnoses for which ECT is an efficacious treatment according to evidence-based standards. METHODS: ECT use among all beneficiaries of a large New England insurance company in 1994 and 1995 was examined using a retrospective cohort design. Associations between provider characteristics and ECT use for diagnoses outside the standards were determined using logistic regression analysis. RESULTS: A total of 996 individuals among approximately 1.2 million beneficiaries were treated with ECT. They received a total of 1,532 ECT courses. For 86.5 percent of the courses, the diagnosis was within evidence-based indications; for 13.5 percent, the diagnosis was outside the indications. In more than half of the 13.5 percent of cases, conditions were depressive disorders for which no studies have been conducted or disorders that likely had associated depressive symptoms. Patients receiving ECT for diagnoses outside evidence-based indications were more likely to have been treated by psychiatrists who graduated from medical school between 1940 and 1960 and between 1961 and 1980 than by those who graduated between 1981 and 1990. These patients were also less likely to have been treated by psychiatrists who received their medical education outside the U.S. CONCLUSIONS: Diagnoses of patients treated with ECT were mostly within evidence-based indications. The results provide reassurance to those concerned that ECT may be used indiscriminately. If confirmed by further research, the finding that psychiatrists trained in earlier eras were more likely to use ECT for diagnoses outside evidence-based indications may offer an opportunity for targeted quality improvement.

Psychotherapy and temporal lobe epilepsy.

This paper describes psychotherapy of a thirty-year-old man with documented temporal lobe epilepsy. After describing the commonly associated neuropsychiatric symptoms and personality syndrome, a case history and summary of treatment are presented. Changes in frequency, duration, and severity of seizures are discussed in relation to psychotherapy.