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.

High-expenditure children with Supplemental Security Income.

OBJECTIVE: To examine the clinical characteristics and health service use of children with high Medicaid expenditures. METHODOLOGY: We examined 1992 Medicaid claims and eligibility files from four states (California, Georgia, Michigan, Tennessee) for children with at least $10000 billed to Medicaid who obtained Medicaid through the Supplemental Security Income (SSI) Program and a comparison group (matched by age group and gender) of children receiving Medicaid for other reasons. We compared mean expenditures, examined expenses by category, and examined diagnoses associated with at least $10000 in expenses. RESULTS: In 1992, Medicaid paid on average approximately $1000 for children with non-SSI Medicaid enrollment. Expenditures for children with SSI were 2.9 to 9.4 times higher, but once the approximately 10% of children with high expenditures were excluded, SSI average expenditures were only 1.5 to 2.7 times higher than the non-SSI average. Children with high expenditures are likely to use hospitals and long-term care, and these services account for more than half of the average expenditures. Children with high expenditures and SSI are more likely to have chronic medical conditions than are their peers enrolled in Medicaid but not through SSI. CONCLUSIONS: A small proportion of children, even on SSI, account for very large proportions of Medicaid expenditures. Most children with SSI, despite having relatively severe mental health, physical, or developmental disabilities, have relatively modest Medicaid expenditures.

Confidentiality and adolescents' use of providers for health information and for pelvic examinations.

OBJECTIVE: To examine the relationship between adolescents' perception of the confidentiality of care provided by their regular health care provider and their reported use of this provider for private health information and for pelvic examinations. DESIGN: Anonymous, self-report survey. SETTING: Thirty-two randomly selected public high schools in Massachusetts. PARTICIPANTS: Of 2224 students in systematically selected 9th and 12th grade classrooms, 1715 (50% male) had a regular provider and a checkup within the last year. RESULTS: Of teens surveyed, 76% wanted the ability to obtain confidential health care, but only 45% perceived their regular provider to provide this, and only 28% had discussed it explicitly. Logistic regression analyses revealed strong relationships between confidentiality and all outcomes studied. Among adolescents, the likelihood of having discussed sexually transmitted diseases, pregnancy prevention, and/or facts about sex with their provider was greater among teens who received a confidentiality assurance than that for teens who did not (odds ratio [OR] = 2.7; 95% confidence interval [CI], 2.2-3.4). A similar relationship for teens' likelihood of having discussed substance use with the provider was found (OR = 1.8; 95% CI, 1.4-2.3). Among sexually active females, the likelihood of a recent pelvic examination for those who received a confidentiality assurance was greater than for those who did not (OR = 3.3; 95% CI, 2.1-5.5). CONCLUSIONS: This study furthers evidence of an important link between teens' perception of confidentiality and use of health care services and information. Because teens' health risks lie largely in potential risks from health-related behaviors, confidentiality in health care may be a critical factor in disclosure and discussion of risky behaviors, and ultimately in appropriate use of health care services. Efforts should be made to increase teens' access to confidential health care sources.

Changing patterns of conditions among children receiving Supplemental Security Income disability benefits.

OBJECTIVE: To determine the relative growth of types of chronic health conditions among children and adolescents receiving Supplemental Security Income (SSI) benefits before and after major SSI program changes, including changes in definitions of childhood disability and outreach to identify eligible children. DESIGN: Retrospective analysis of Medicaid claims from California, Georgia, Michigan, and Tennessee. PARTICIPANTS: All children (aged < or = 21 years) newly enrolled in SSI programs in these states from July 1989 (n=21 222) to June 1992 (n=38 789). METHODS: Medicaid data indicate eligibility status and diagnoses for services rendered. For children newly enrolled before (time 1, July 1989 to June 1990), during (time 2, July 1990 to June 1991), and after (time 3, July 1991 to June 1992) the program changes, we used claims for the first 6 months of enrollment to determine rates of chronic conditions in general and rates of asthma, attention-deficit/hyperactivity disorder (ADHD), and mental retardation specifically. We also followed up time 1 enrollees during the study period to determine the likelihood of a chronic condition claim at any time. MAIN OUTCOME MEASURE: Presence of claims for chronic conditions. RESULTS: New SSI enrollees almost doubled during the study period. Increasing numbers of new enrollees had chronic condition claims in their first 6 months (from 29% to 36%); 58% of time 1 enrollees had such claims during any study month. Rates of chronic physical conditions other than asthma increased 14% (time 1 to time 3); asthma rates increased 73%. Rates of mental health conditions other than mental retardation and ADHD increased 63%; rates of mental retardation decreased 29%, while rates of ADHD increased almost 3-fold. CONCLUSIONS: The number of children with chronic conditions receiving SSI benefits experienced rapid growth from 1989 to 1992. Growth was particularly marked for children with diagnoses of asthma and ADHD.

Do elderly Medicaid patients experience reduced access to nursing home care?

This paper uses data from the National Long-Term Care Survey and the Area Resources File to analyze the problem of diminished access to nursing home care for elderly Medicaid patients. Using a proxy for the length of time on a waiting list before nursing home entry as my measure of access, I find evidence suggesting that nursing home operators in some areas preferentially admit private patients. Waitlisting of Medicaid patients appears to be a problem mainly in counties in which a high proportion of potential nursing home patients are private and counties in which bed supply is low.

New evidence on the relationship between income and health.

Using data from the National Survey of Families and Households, the Survey of Income and Program Participation, and the National Health Interview Survey, I estimate the structural impact of income on the following measures of health: self-assessed health status, work and functional limitations, bed days, average daily consumption of alcohol, and scales of depressive symptoms and alcoholic behavior. Both ordinary and IV estimates indicate that increases in income significantly improve mental and physical health but increase the prevalence of alcohol consumption. Cost-benefit analyses of government policies that may reduce disposable income should take into account potential effects on morbidity.

Adverse selection and the purchase of Medigap insurance by the elderly.

This study uses data on 8561 elderly respondents from the 1991 Medicare Current Beneficiary Survey to examine adverse selection in the supplemental private insurance market. Logit models of supplemental insurance choices provided modest but mixed evidence of self-selection on the basis of observable health status. Wealth had a strong influence on coverage. Two part models of Medicare utilization and expenditures showed that beneficiaries with individually purchased policies had higher total, part B and physician expenditures than those with employer-provided policies, even after controlling for observable differences, suggesting adverse selection. Results were similar for basic and more comprehensive policies.

The role of profit status under imperfect information: evidence from the treatment patterns of elderly medicare beneficiaries hospitalized for psychiatric diagnoses.

Medicare claims for elderly admitted for psychiatric care were used to estimate the impact of hospital profit status on costs, length of stay (LOS), and rehospitalizations. No evidence was found that not-for-profits (NFPs) treated sicker patients or had fewer rehospitalizations. For-profits (FPs) actually treated poorer patients. Longer LOS and lower daily costs of NFPs were attributable to their other characteristics, e.g. medical school affiliation. Instrumental variables (IV) estimates suggested that NFP general hospitals actually have lower adjusted costs. These findings fail to support concerns that FP growth leads to declining access and quality or contentions that NFPs are less efficient.

Differences between generalists and mental health specialists in the psychiatric treatment of Medicare beneficiaries.

OBJECTIVE: To examine differences between the general medical and mental health specialty sectors in the expenditure and treatment patterns of aged and disabled Medicare beneficiaries with a physician diagnosis of psychiatric disorder. DATA SOURCES: Based on 1991-1993 Medicare Current Beneficiary Survey data, linked to the beneficiary's claims and area-level data on provider supply from the Area Resources File and the American Psychological Association. STUDY DESIGN: Outcomes examined included the number of psychiatric services received, psychiatric and total Medicare expenditures, the type of services received, whether or not the patient was hospitalized for a psychiatric disorder, the length of the psychiatric care episode, the intensity of service use, and satisfaction with care. We compared these outcomes for beneficiaries who did and did not receive mental health specialty services during the episode, using multiple regression analyses to adjust for observable population differences. We also performed sensitivity analyses using instrumental variables techniques to reduce the potential bias arising from unmeasured differences in patient case mix across sectors. PRINCIPAL FINDINGS: Relative to beneficiaries treated only in the general medical sector, those seen by a mental health specialist had longer episodes of care, were more likely to receive services specific to psychiatry, and had greater psychiatric and total expenditures. Among the elderly persons, the higher costs were due to a combination of longer episodes and greater intensity; among the persons who were disabled, they were due primarily to longer episodes. Some evidence was also found of higher satisfaction with care among the disabled individuals treated in the specialty sector. However, evidence of differences in psychiatric hospitalization rates was weaker. CONCLUSIONS: Mental health care provided to Medicare beneficiaries in the general medical sector does not appear to substitute perfectly for care provided in the specialty sector. Our study suggests that the treatment patterns in the specialty sector may be preferred by some patients; further, earlier findings indicate geographic barriers to obtaining specialty care. Thus, the matching of service use to clinical need among this vulnerable population may be inappropriate. The need for further research on outcomes is indicated.

Risk adjustment alternatives in paying for behavioral health care under Medicaid.

OBJECTIVE: To compare the performance of various risk adjustment models in behavioral health applications such as setting mental health and substance abuse (MH/SA) capitation payments or overall capitation payments for populations including MH/SA users. DATA SOURCES/STUDY DESIGN: The 1991-93 administrative data from the Michigan Medicaid program were used. We compared mean absolute prediction error for several risk adjustment models and simulated the profits and losses that behavioral health care carve outs and integrated health plans would experience under risk adjustment if they enrolled beneficiaries with a history of MH/SA problems. Models included basic demographic adjustment, Adjusted Diagnostic Groups, Hierarchical Condition Categories, and specifications designed for behavioral health. PRINCIPAL FINDINGS: Differences in predictive ability among risk adjustment models were small and generally insignificant. Specifications based on relatively few MH/SA diagnostic categories did as well as or better than models controlling for additional variables such as medical diagnoses at predicting MH/SA expenditures among adults. Simulation analyses revealed that among both adults and minors considerable scope remained for behavioral health care carve outs to make profits or losses after risk adjustment based on differential enrollment of severely ill patients. Similarly, integrated health plans have strong financial incentives to avoid MH/SA users even after adjustment. CONCLUSIONS: Current risk adjustment methodologies do not eliminate the financial incentives for integrated health plans and behavioral health care carve-out plans to avoid high-utilizing patients with psychiatric disorders.

Provider specialty choice among Medicare beneficiaries treated for psychiatric disorders.

This study estimates the probability of mental health specialist use among elderly and disabled Medicare beneficiaries treated for a primary psychiatric diagnosis, based on the 1991 Medicare Current Beneficiary Survey (MCBS) and physician claims. Beneficiaries with psychotic and affective disorders or multiple psychiatric diagnoses had a higher probability of specialty use, as did beneficiaries in counties with greater psychiatrist density. Elderly in counties with greater general practitioner density and disabled in counties with greater psychologist density were less likely to see a specialist, suggesting possible provider substitution. Government programs to recruit and retain mental health professionals in underserved areas may change provider specialty choices among Medicare beneficiaries treated for psychiatric disorders.

Impact of expanding SSI on Medicaid expenditures of disabled children.

Supplemental Security Income (SSI) expansions for disabled children in the early 1990s provoked criticism that eligibility criteria were too lax and motivated the subsequent retraction of benefits for many children. However, little evidence exists on whether the clinical needs of SSI children declined during this period. The authors used Medicaid data to examine changes in average expenditures between 1989 and 1992, using an Aid to Families with Dependent Children (AFDC) comparison group to control for confounding time trends (e.g., in access). Results showed declines in average expenditures in Georgia and Tennessee but increases in California and Michigan, which are thought to have started with more liberal eligibility policies.

Measuring the human cost of a weak economy: does unemployment lead to alcohol abuse?

This paper uses two-stage instrumental variables methods to examine whether unemployment affects alcohol use and symptoms of dependence, and if so, in which direction. Data were obtained from the 1988 National Health Interview Survey. The outcomes examined were average daily consumption during the previous two weeks and a summary measure of the number of symptoms related to alcohol dependence during the previous year. After eliminating potential bias due to reverse causality, evidence was found that non-employment significantly reduces both alcohol consumption and dependence symptoms, probably due to an income effect. Involuntary unemployment had a mixed effect-job loss increased the consumption of alcohol in the overall sample but reduced dependence symptoms among single respondents. Studies of the impact of alcohol use on economic outcomes should take potential reverse causality into account.

Performance of Massachusetts HMOs in providing Pap smear and sexually transmitted disease screening to adolescent females.

PURPOSE: To describe the extent to which health maintenance organizations (HMOs) provide preventive health services to female adolescent enrollees. METHODS: All Massachusetts HMOs were asked to provide 1992 Papanicolaou (Pap) smear, gonorrhea, chlamydia, syphilis, and human immunodeficiency virus test rates for adolescents from medical records and claims data. The rates were compared with criterion standards and national utilization data from the National Survey of Family Growth. Seven of 14 Massachusetts HMOs agreed to provide data for female members aged 15-21 years on the Pap smear rate (n = 34,415) and sexually transmitted disease (STD) test rate (n = 33,701). RESULTS: Papanicolaou smear rates for females in the HMOs ranged from 5% of 15-year-olds to 45% of 21-year-olds during 1992. Test rates for chlamydia and gonorrhea ranged from 2% and 3%, respectively, for 15-year-olds to 9% and 10% for 21-year-olds. Among 15-19-year-old females, only 18% received a Pap smear, and only 11% received an STD test through their HMO during 1992, despite professional guidelines recommending that all of the estimated 53% of sexually active females age 15-19 years should receive both Pap smears and STD tests. Among 18-21-year-old females, only 37% had had a Pap smear through their HMO during 1992, despite professional guidelines recommending Pap smears for all women age 18 years and over. CONCLUSIONS: Efforts are needed within HMOs to ensure that STD screening, Pap smears, and other health screening services are provided for sexually active adolescent enrollees.

The setting of psychiatric care for medicare recipients in general hospitals with specialty units.

This study examined the patient and hospital characteristics associated with whether patients with psychiatric disorders were treated on the psychiatric unit or on medical wards after admission to general hospitals with psychiatric units. Medicare data for 169,798 beneficiaries who had psychiatric disorders and were admitted to general hospitals with psychiatric units were used to estimate logistic regressions of the probability of treatment on the unit. Results showed that beneficiaries who had more than one psychiatric diagnosis (except for substance use disorders), state buy-in coverage such as Medicaid, or previous psychiatric hospitalizations or who had ever been eligible for Medicare through disability were more likely to be treated on the unit. Those who were older, admitted through the emergency department, or had greater medical morbidity or primary diagnoses other than schizophrenia or bipolar or major affective disorders were less likely to be treated on the unit.

Inpatient psychiatric treatment of elderly Medicare beneficiaries.

OBJECTIVE: The clinical characteristics and treatment patterns of elderly Medicare beneficiaries hospitalized for psychiatric disorders were examined. METHODS: Administrative data on all elderly Medicare beneficiaries in the United States hospitalized in a nonfederal hospital for a primary psychiatric disorder in 1990-1991 were used to calculate descriptive statistics on case-mix by age group, hospital type (psychiatric hospital, general hospital psychiatric unit, or general hospital nonpsychiatric unit), and primary diagnosis. Length of stay, costs, and discharge destination by hospital type and primary diagnosis were also determined. RESULTS: A total of .6 percent of elderly Medicare beneficiaries were hospitalized for a psychiatric disorder in 1990, accounting for more than 240,000 admissions and $1 billion in Medicare payments. The most common reasons for hospitalization were major depressive disorder (28.1 percent), dementia and other organic disorders (26.8 percent), and substance-related disorders (12.6 percent). Organic disorders were particularly prevalent among the oldest old, accounting for more than half of psychiatric admissions among those 85 and older. A total of 43 percent of the psychiatric admissions were to general hospital nonpsychiatric units, 38 percent to general hospital psychiatric units, and only 19 percent to psychiatric hospitals. Within each diagnostic category, patients admitted to general hospital nonpsychiatric units had the shortest average lengths of stay and the lowest average costs. Among beneficiaries with organic, affective, and psychotic disorders other than schizophrenia, those admitted to general hospitals had shorter lengths of stay, higher rates of discharge to nursing homes, and lower rates of discharge to self-care than those treated in psychiatric hospitals. CONCLUSIONS: Case-mix-adjusted treatment patterns varied substantially across hospital types, due to differences in either illness severity or treatment styles.

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.

How low birthweight and gestational age contribute to increased inpatient costs for multiple births.

The dramatic rise in the number of multiple gestation births has led to concerns about heavy resource use by these newborns and the design of cost-effective interventions. This study uses medical records data to compare single and multiple births in terms of hospital charges by cost center, length of stay, neonatal intensive care unit (NICU) days, and discharge status. Potential mediators examined were gestational age and birthweight. These factors, respectively, accounted for 50% and 40% of the increase in total charges due to multiple gestation. The remaining "direct effect" was due primarily to longer hospital stays among twins and higher daily charges among higher-order multiples. Room and board charges were higher for multiples, while charges in other categories were actually lower, after controlling for birthweight and gestational age. Birthweight and gestational age accounted fully for the increased use of NICU services among multiples. These results show that while prevention of multiple gestation, where possible, is of paramount importance, strategies that decrease preterm delivery and/or increase birthweight should attenuate the adverse economic impact of multiple gestation pregnancies.

Risk adjustment of mental health and substance abuse payments.

This study used 1992 and 1993 data from private employers to compare the performance of various risk adjustment methods in predicting the mental health and substance abuse expenditures of a nonelderly insured population. The methods considered included a basic demographic model, Ambulatory Care Groups, modified Ambulatory Diagnostic Groups and Hierarchical Coexisting Conditions (a modification of Diagnostic Cost Groups), as well as a model developed in this paper to tailor risk adjustment to the unique characteristics of psychiatric disorders (the "comorbidity" model). Our primary concern was the amount of unexplained systematic risk and its relationship to the likelihood of a health plan experiencing extraordinary profits or losses stemming from enrollee selection. We used a two-part model to estimate mental health and substance abuse spending. We examined the R2 and mean absolute prediction error associated with each risk adjustment system. We also examined the profits and losses that would be incurred by the health plans serving two of the employers in our database, based on the naturally occurring selection of enrollees into these plans. The modified Ambulatory Diagnostic Groups and comorbidity model performed somewhat better than the others, but none of the models achieved R2 values above .10. Furthermore, simulations based on actual plan choices suggested that none of the risk adjustment methods reallocated payments across plans sufficiently to compensate for systematic selection.

Workers' perceptions of how jobs affect health: a social ecological perspective.

A national sample of 2,048 workers was asked to rate the impact of their job on their physical and mental health. Ordered logistic regression analyses based on social ecology theory showed that the workers' responses were significantly correlated with objective and subjective features of their jobs, in addition to personality characteristics. Workers who had higher levels of perceived constraints and neuroticism, worked nights or overtime, or reported serious ongoing stress at work or higher job pressure reported more negative effects. Respondents who had a higher level of extraversion, were self-employed, or worked part time or reported greater decision latitude or use of skills on the job reported more positive effects. These findings suggest that malleable features of the work environment are associated with perceived effects of work on health, even after controlling for personality traits and other sources of reporting bias.