Learning from national implementation of the Veterans Affairs Clinical Resource Hub (CRH) program for improving access to care: protocol for a six year evaluation.

BACKGROUND: The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VA's Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation. The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams. METHODS: The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluation's overall goal is to assess CRH's return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners. DISCUSSION: Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

Federally Qualified Health Center Substitution of Local Health Department Services.

INTRODUCTION: Strategic and budgetary considerations have shifted local health departments (LHDs) away from safety net clinical services and toward population-focused services. Federally Qualified Health Centers (FQHCs) play an increasing role in the safety net, and may complement or substitute for LHD clinical services. The authors examined the association between FQHC service levels in communities and the presence of specific LHD clinical services in 2010 and 2013. METHODS: Data from LHD surveys and FQHC service data were merged for 2010 and 2013. Multivariate regression and instrumental variable methods were used to examine FQHC service levels that might predict related LHD service presence or discontinuation from 2010 to 2013. RESULTS: There were modest reductions in LHD service presence and increases in FQHC service volume over the time period. LHD primary care and dental service presence were inversely associated with higher related FQHC service volume. LHD prenatal care service presence, as well as a measure of change in general service approach, were not significantly associated with FQHC service volume. CONCLUSIONS: LHDs were less likely to provide certain clinical services where FQHCs provide a greater volume of services, suggesting a substitution effect. However, certain clinical services, such as prenatal care, may complement the public health mission-and LHDs may be strategically placed to continue to deliver these services.

Neighborhood Crime-Related Safety and Its Relation to Children's Physical Activity.

Crime is both a societal safety and public health issue. Examining different measures and aspects of crime-related safety and their correlations may provide insight into the unclear relationship between crime and children's physical activity. We evaluated five neighborhood crime-related safety measures to determine how they were interrelated. We then explored which crime-related safety measures were associated with children's total moderate-to-vigorous physical activity (MVPA) and MVPA in their neighborhoods. Significant positive correlations between observed neighborhood incivilities and parents' perceptions of general crime and disorder were found (r = 0.30, p = 0.0002), as were associations between parents' perceptions of general crime and disorder and perceptions of stranger danger (r = 0.30, p = 0.0002). Parent report of prior crime victimization in their neighborhood was associated with observed neighborhood incivilities (r = 0.22, p = 0.007) and their perceptions of both stranger danger (r = 0.24, p = 0.003) and general crime and disorder (r = 0.37, p < 0.0001). After accounting for covariates, police-reported crime within the census block group in which children lived was associated with less physical activity, both total and in their neighborhood (beta = -0.09, p = 0.005, beta = -0.01, p = 0.02, respectively). Neighborhood-active children living in the lowest crime-quartile neighborhoods based on police reports had 40 min more of total MVPA on average compared to neighborhood-active children living in the highest crime-quartile neighborhoods. Findings suggest that police reports of neighborhood crime may be contributing to lower children's physical activity.

Targeted health department expenditures benefit birth outcomes at the county level.

BACKGROUND: Public health leaders lack evidence for making decisions about the optimal allocation of resources across local health department (LHD) services, even as limited funding has forced cuts to public health services while local needs grow. A lack of data has also limited examination of the outcomes of targeted LHD investments in specific service areas. PURPOSE: This study used unique, detailed LHD expenditure data gathered from state health departments to examine the influence of maternal and child health (MCH) service investments by LHDs on health outcomes. METHODS: A multivariate panel time-series design was used in 2013 to estimate ecologic relationships between 2000-2010 LHD expenditures on MCH and county-level rates of low birth weight and infant mortality. The unit of analysis was 102 LHD jurisdictions in Washington and Florida. RESULTS: Results indicate that LHD expenditures on MCH services have a beneficial relationship with county-level low birth weight rates, particularly in counties with high concentrations of poverty. This relationship is stronger for more targeted expenditure categories, with expenditures in each of the three specific examined MCH service areas demonstrating the strongest effects. CONCLUSIONS: Findings indicate that specific LHD investments in MCH have an important effect on related health outcomes for populations in poverty and likely help reduce the costly burden of poor birth outcomes for families and communities. These findings underscore the importance of monitoring the impact of these evolving investments and ensuring that targeted, beneficial investments are not lost but expanded upon across care delivery systems.

Children's objective physical activity by location: why the neighborhood matters.

Knowledge of where children are active may lead to more informed policies about how and where to intervene and improve physical activity. This study examined where children aged 6-11 were physically active using time-stamped accelerometer data and parent-reported place logs and assessed the association of physical-activity location variation with demographic factors. Children spent most time and did most physical activity at home and school. Although neighborhood time was limited, this time was more proportionally active than time in other locations (e.g., active 42.1% of time in neighborhood vs. 18.1% of time at home). Children with any neighborhood-based physical activity had higher average total physical activity. Policies and environments that encourage children to spend time outdoors in their neighborhoods could result in higher overall physical activity.

The reliability of medical group performance measurement in a single insurer's pay for performance program.

BACKGROUND: Most public reporting and pay for performance (P4P) programs in the United States continue to be organized and implemented by single insurers. Adequate medical group-level reliability on clinical care process measures is possible in multistakeholder initiatives because patient samples can be pooled across payers. However, the extent to which reliable measurement is achievable in single insurer P4P initiatives remains unclear. METHODS: This study uses 7 years (2001 to 2007) of patient-level clinical care process data from an insurer in Washington State involving 20 medical groups. Eight clinical care process measures were analyzed. We compared the medical group-level reliability and resulting sample size requirements for each of the 8 measures using unadjusted and adjusted binary mixed models. The relation of baseline intraclass correlation coefficients (ICCs) and medical group performance change over time was examined for each clinical care process measure. RESULTS: Only 45% of all medical group measurements (group-years for all observations) had sufficient sample sizes to achieve reliable estimates of group performance. Measures with the largest deficiencies in patient samples per group included appropriate asthma treatment and low-density lipoprotein screening for patients with coronary artery disease. There was an inconsistent relationship between the size of baseline ICCs and medical group performance improvement over time. CONCLUSIONS: Unreliable performance measurement is an important consequence of the prevailing organization and implementation of public reporting and P4P programs in the US. Multi-payer collaborations may be an important vehicle for ensuring reliable medical group performance measurement and comparisons on clinical care process measures.

Implementation and progress of an inclusive primary health care model in Guatemala: coverage, quality, and utilization.

OBJECTIVE: To describe a primary health care model designed specifically for Guatemala that has been implemented in two demonstration sites since 2004 and present results of a process evaluation of utilization, service coverage, and quality of care from 2005 to 2009. METHODS: Coverage, utilization, and quality were assessed by using an automated database linking census and clinical records and were reported over time. Key maternal and child health coverage measures were compared with national-level measures. RESULTS: The postnatal coverage achieved by the Modelo Incluyente de Salud of nearly 100.0% at both sites contrasts with the national average of 25.6%. Vaccination coverage for children aged 12-23 months in the Modelo Incluyente de Salud reached 95.6% at site 1 (Bocacosta, Sololá) and 92.7% at site 2 (San Juan Ostuncalco), compared with the national average of 71.2%. Adherence to national treatment guidelines increased significantly at both sites with a marked increase between 2006 and 2007. Utilization increased significantly at both sites, with only 7.5% of families at site 1 and 11.2% of families at site 2 not using services by the end of the 5-year period. CONCLUSIONS: Coverage, quality of care, and utilization measures increased significantly during the 5-year period when the service delivery model was implemented. This finding suggests a strong possibility that the model may have a benefit for health outcomes as well as for process measures. The Modelo Incluyente de Salud will be financially sustained by the Ministry of Health and extended to at least three additional sites. The model provides important lessons for primary care programs internationally.

Implementation and progress of an inclusive primary health care model in Guatemala: coverage, quality, and utilization / Ejecución y avance de un modelo inclusivo de atención primaria de salud en Guatemala: cobertura, calidad y utilización

OBJECTIVE: To describe a primary health care model designed specifically for Guatemala that has been implemented in two demonstration sites since 2004 and present results of a process evaluation of utilization, service coverage, and quality of care from 2005 to 2009. METHODS: Coverage, utilization, and quality were assessed by using an automated database linking census and clinical records and were reported over time. Key maternal and child health coverage measures were compared with national-level measures. RESULTS: The postnatal coverage achieved by the Modelo Incluyente de Salud of nearly 100.0 percent at both sites contrasts with the national average of 25.6 percent. Vaccination coverage for children aged 12-23 months in the Modelo Incluyente de Salud reached 95.6 percent at site 1 (Bocacosta, Sololá) and 92.7 percent at site 2 (San Juan Ostuncalco), compared with the national average of 71.2 percent. Adherence to national treatment guidelines increased significantly at both sites with a marked increase between 2006 and 2007. Utilization increased significantly at both sites, with only 7.5 percent of families at site 1 and 11.2 percent of families at site 2 not using services by the end of the 5-year period. CONCLUSIONS: Coverage, quality of care, and utilization measures increased significantly during the 5-year period when the service delivery model was implemented. This finding suggests a strong possibility that the model may have a benefit for health outcomes as well as for process measures. The Modelo Incluyente de Salud will be financially sustained by the Ministry of Health and extended to at least three additional sites. The model provides important lessons for primary care programs internationally.

OBJETIVO: Describir un modelo de atención primaria de salud diseñado específicamente para Guatemala que se ha ejecutado en dos sitios piloto desde 2004 y presentar los resultados de una evaluación de la utilización, la cobertura de servicios y la calidad de la atención entre 2005 y 2009. MÉTODOS: Se evaluaron la cobertura, la utilización y la calidad mediante una base de datos automatizada que relaciona los datos obtenidos a partir de un censo con los registros clínicos, y su evolución se informó a lo largo del tiempo. Se compararon las medidas clave de cobertura de la salud maternoinfantil con las medidas obtenidas en el nivel nacional. RESULTADOS: La cobertura posnatal lograda por el Modelo Incluyente de Salud, de casi 100,0 por ciento en ambos sitios, contrasta con el promedio nacional de 25,6 por ciento. La cobertura de vacunación de los niños de 12 a 23 meses de edad en dicho modelo alcanzó 95,6 por ciento en el sitio 1 (Bocacosta, Sololá) y 92,7 por ciento en el sitio 2 (San Juan Ostuncalco), en comparación con el promedio nacional de 71,2 por ciento. El cumplimiento de las directrices nacionales de tratamiento aumentó significativamente en los dos sitios, con un aumento acentuado entre 2006 y 2007. La utilización aumentó significativamente en ambos sitios; al finalizar el período de 5 años no usaban los servicios solo 7,5 por ciento de las familias en el sitio 1 y 11,2 por ciento de las familias en el sitio 2. CONCLUSIONES: Las medidas de cobertura, calidad de la atención y utilización aumentaron significativamente durante el período de 5 años durante el cual se ejecutó el modelo de prestación de servicios. Estos datos indican firmemente que el modelo puede mejorar tanto los resultados relacionados con la salud como las medidas de proceso. El Modelo Incluyente de Salud será mantenido económicamente por el Ministerio de Salud Pública y Asistencia Social y se extenderá, al menos, a tres sitios más. El modelo proporciona enseñanzas importantes para los programas de atención primaria de otros países.

Chiropractic use by urban and rural residents with insurance coverage.

PURPOSE: To describe the use of chiropractic care by urban and rural residents in Washington state with musculoskeletal diagnoses, all of whom have insurance coverage for this care. The analyses investigate whether restricting the analyses to insured individuals attenuates previously reported differences in the prevalence of chiropractic use between urban and rural residents as well as whether differences in provider availability or patient cost-sharing explain the difference in utilization. METHODS: Claims data from 237,500 claimants in 2 large insurance companies in Washington state for calendar year 2002 were analyzed, using adjusted clinical group risk adjustment for differences in disease burden and rural urban commuting area codes for rurality definition. FINDINGS: The proportion of claimants using chiropractors was higher in rural than urban residents (44% vs 32%, P < .001). Lack of conventional providers in rural areas did not completely explain this difference, nor did differences in patient cost-sharing or demographics. Among those who used chiropractors, those in urban areas had more chiropractic visits than users of chiropractic in rural areas. CONCLUSIONS: Among insured adults, use of chiropractic care was higher in rural than in urban areas. Reasons suggested for this difference in previous reports were not borne out in this data set.

Physician effects on racial and ethnic disparities in patients' experiences of primary care.

BACKGROUND: Few studies have clarified the mechanisms that contribute to racial and ethnic disparities in primary care quality among comparably-insured patients. OBJECTIVE: To examine relative contribution of "between-" and "within-" physician effects on disparities in patients' experiences of primary care. DESIGN: Regression models using physician fixed effects to account for patient clustering were specified to assess "between-" and "within-"physician effects on observed racial and ethnic disparities in patients' experiences of primary care. PARTICIPANTS: The Ambulatory Care Experiences Survey (ACES) was administered to patients visiting 1,588 primary care physicians (PCPs) from 27 California medical groups. The analytic sample included 49,861 patients (31.4 per PCP) who confirmed a PCP visit during the preceding 12 months. MAIN RESULTS: Most racial and ethnic minority groups were significantly clustered within physician practices (p < 0.001). "Between-physician" effects were mostly negative and larger than "within-physician" effects for Latinos, Blacks, and American Indian/Alaskan Natives, indicating that disparities are mainly attributable to patient clustering within physician practices with lower performance on patient experience measures. By contrast, "within-physician" effects accounted for most disparities for Asians and Pacific Islanders, indicating these groups report worse experiences relative to Whites in the same practices. Practices with greater concentration of Blacks, Latinos and Asians had lower performance on patient experience measures (p < 0.05). CONCLUSIONS: Targeting patient experience improvement efforts at low performing practices with high concentrations of racial and ethnic minorities might efficiently reduce disparities. Urgent study is needed to assess the contribution of "within-" and "between-" physician effects to racial and ethnic disparities in the technical quality of primary care.

Use of complementary and alternative medicine providers by fibromyalgia patients under insurance coverage.

OBJECTIVE: To quantify how visits and expenditures differ between insured patients with fibromyalgia syndrome (FMS) who visit complementary and alternative medicine (CAM) providers compared with patients with FMS who do not. Patients with FMS were also compared with an age- and sex-matched comparison group without FMS. METHODS: Calendar year 2002 claims data from 2 large insurers in Washington state were analyzed for provider type (CAM versus conventional), patient comorbid medical conditions, number of visits, and expenditures. RESULTS: Use of CAM by patients with FMS was 2.5 times higher than in the comparison group without FMS (56% versus 21%). Patients with FMS who used CAM had more health care visits than patients with FMS not using CAM (34 versus 23; P < 0.001); however, CAM users had similar expenditures to nonusers among patients with FMS ($4,638 versus $4,728; not significant), because expenditure per CAM visit is lower than expenditure per conventional visit. Patients with FMS who used CAM also had heavier overall disease burdens than those not using CAM. CONCLUSION: With insurance coverage, a majority of patients with FMS will visit CAM providers. The sickest patients use more CAM, leading to an increased number of health care visits. However, CAM use is not associated with higher overall expenditures. Until a cure for FMS is found, CAM providers may offer an economic alternative for patients with FMS seeking symptomatic relief.

The effect of complementary and alternative medicine claims on risk adjustment.

OBJECTIVE: We sought to assess how the inclusion of claims from complementary and alternative medicine (CAM) providers affects measures of morbidity burden and expectations of health care resource use for insured patients. METHODS: Claims data from Washington State were used to create 2 versions of a case-mix index. One version included claims from all provider types; the second version omitted claims from CAM providers who are covered under commercial insurance. Expected resource use was also calculated. The distribution of expected and actual resource use was then compared for the 2 indices. RESULTS: Inclusion of claims from CAM providers shifted 19,650 (32%) CAM users into higher morbidity categories. When morbidity categories were defined using claims from all providers, CAM users in the highest morbidity category had average (+/-SD) annual expenditures of $6661 (+/-$13,863). This was less than those in the highest morbidity category when CAM provider claims were not included in the index ($8562 +/- $16,354), and was also lower than the highest morbidity patients who did not use any CAM services ($8419 +/- $18,885). CONCLUSIONS: Inclusion of services from CAM providers under third-party payment increases risk scores for their patients but expectations of costs for this group are lower than expected had costs been estimated based only on services from traditional providers. Risk adjustment indices may need recalibration when adding services from provider groups not included in the development of the index.

Insurance coverage and subsequent utilization of complementary and alternative medicine providers.

BACKGROUND: Since 1996, Washington State law has required that private health insurance cover licensed complementary and alternative medicine (CAM) providers. OBJECTIVE: To evaluate how insured people used CAM providers and what role this played in healthcare utilization and expenditures. STUDY DESIGN: Cross-sectional analysis of insurance enrollees from western Washington in 2002. METHODS: Analysis of insurance demographic data, claims files, benefit information, diagnoses, CAM and conventional provider utilization, and healthcare expenditures for 3 large health insurance companies. RESULTS: Among more than 600,000 enrollees, 13.7% made CAM claims. This included 1.3% of enrollees with claims for acupuncture, 1.6% for naturopathy, 2.4% for massage, and 10.9% for chiropractic. Patients enrolled in preferred provider organizations and point-of-service products were notably more likely to use CAM than those with health maintenance organization coverage. The use of CAM was greater among women and among persons 31 to 50 years of age. The use of chiropractic was more frequent in less populous counties. The CAM provider visits usually focused on musculoskeletal complaints except for naturopathic physicians, who treated a broader array of problems. The median per-visit expenditures were 39.00 dollars for CAM care and 74.40 dollars for conventional outpatient care. The total expenditures per enrollee were 2589 dollars, of which 75 dollars(2.9%) was spent on CAM. CONCLUSIONS: The number of people using CAM insurance benefits was substantial; the effect on insurance expenditures was modest. Because the long-term trajectory of CAM cost under third-party payment is unknown, utilization of these services should be followed.

Complementary and alternative provider use by insured patients with diabetes in Washington State.

OBJECTIVES: The authors investigated whether insurance coverage for complementary and alternative medicine (CAM) providers is associated with increased medical care use among diabetes patients. Predictors of CAM use and how CAM affects health care use and expenditures under insurance coverage were examined. DESIGN: Claims data from two large insurers in Washington State were obtained for 2002. Types of providers used, comorbid medical conditions, number of visits, and expenditures were calculated for the study sample and compared to a nondiabetic matched group. RESULTS: Of the 20,722 adults with diabetes, 3605 (17.4%) had one or more visits to any licensed CAM provider (mostly chiropractors). This was lower than the 20% CAM use in the comparison group. Diabetes patients who used CAM were more likely to have multiple other medical problems than CAM nonusers. CAM users had a higher average number of annual outpatient visits compared to nonusers (28 versus 16), and higher average annual expenditures (8,736 dollars versus 7,356 dollars); however, after adjustment for disease load and other factors, CAM use was not a significant predictor of expenditures. CAM use was <2% of the overall mean medical expenditures for diabetes patients. Quality of conventional care was similar for CAM users and nonusers. CONCLUSIONS: CAM provider usage when covered by insurance is lower among diabetes patients than in adults without diabetes and represents a small proportion of diabetes care costs. Very few CAM visits were related directly to diabetes care. CAM-using patients often have heavy disease burdens and high total expected resource use compared to those not using CAM.

Early orthodontic treatment as a means to increase access for children enrolled in Medicaid in Washington state.

BACKGROUND: The authors assessed the likelihood that interceptive orthodontic Medicaid programs would increase access to care for Washington children. METHODS: The authors surveyed 210 Washington state orthodontists, including questions on demographics, attitudes toward early treatment, use of innovations and perceptions of Medicaid. Respondents were either Medicaid participants or nonparticipants. RESULTS: Fifty of 159 respondents were Medicaid participants. Most respondents perceived early orthodontic treatment as beneficial. Medicaid participants were more willing to participate in Medicaid early-treatment programs, had slightly fewer patients in the "other insurance" category, provided more discounted fees, received more Medicaid inquiries, practiced in rural areas with lower household incomes, reported feeling overworked and experienced fewer Medicaid problems. The principal problem reported with the Medicaid system was low fee reimbursement. CONCLUSIONS: Programs offering early orthodontic treatment could increase access. Important barriers would be low fees and unfamiliarity with Medicaid. PRACTICE IMPLICATIONS: Medicaid should design programs aimed at early treatment with reasonable reimbursement and an educational component.

Managed care and patient-rated quality of care from primary physicians.

The aim is to determine the associations between managed care controls and patient-rated quality of care from primary physicians. In a prospective cohort study, 17,187 patients were screened in the waiting rooms of 261 primary care physicians in the Seattle metropolitan area (1996-1997) to identify 2,850 English-speaking adult patients with depressive symptoms and/or selected pain problems. Patients completed 6-month follow-ups to rate the quality of care from their primary physicians. The intensity of managed care was measured for each patient's health plan, primary care office, and physician. Regression analyses revealed that patients in more managed plans and offices had lower ratings of the quality of care from their primary physicians. Managed care controls targeting physicians were generally not associated with patient ratings.

Managed care, access to specialists, and outcomes among primary care patients with pain.

OBJECTIVE: To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain. DATA SOURCES/STUDY SETTING: Patient, physician, and office manager questionnaires collected in the Seattle area in 1996-1997, plus data abstracted from patient records and health plans. STUDY DESIGN: A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle. DATA COLLECTION: Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines. PRINCIPAL FINDINGS: A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians. CONCLUSIONS: Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.

Managed care and the US health care system a social exchange perspective.

Many countries are importing managed care and price competition from the US to improve the performance of their health care systems. However, relatively little is known about how power is organized and exercised in the US health care system to control costs, improve quality and achieve other objectives. To close this knowledge gap, we applied social exchange theory to examine the power relations between purchasers, managed care organizations, providers and patients in the US health care system at three interrelated levels: (1) exchanges between purchasers and managed care organizations (MCOs); (2) exchanges between MCOs and physicians; and (3) exchanges between physicians and patients. The theory and evidence indicated that imbalanced exchange, or dependence, at all levels prompts behavior to move the exchange toward power balance. Collective action is a common strategy at all levels for reducing dependence and therefore, increasing power in exchange relations. The theoretical and research implications of exchange theory for the comparative study of health care systems are discussed.

Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms.

OBJECTIVE: To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms. DESIGN: Prospective cohort study. SETTING: Offices of 261 primary physicians in private practice in Seattle. PATIENTS: Patients (N = 17,187) were screened in waiting rooms, enrolling 1,336 adults with depressive symptoms. Patients (n = 942) completed follow-up surveys at 1, 3, and 6 months. MEASUREMENTS AND RESULTS: For each patient, the intensity of managed care was measured by the managedness of the patient's health plan, plan benefit indexes, presence or absence of a mental health carve-out, intensity of managed care in the patient's primary care office, physician financial incentives, and whether the physician read or used depression guidelines. Access measures were referral and actually seeing a mental health specialist. Outcomes were the Symptom Checklist for Depression, restricted activity days, and patient rating of care from primary physician. Approximately 23% of patients were referred to mental health specialists, and 38% saw a mental health specialist with or without referral. Managed care generally was not associated with a reduced likelihood of referral or seeing a mental health specialist. Patients in more-managed plans were less likely to be referred to a psychiatrist. Among low-income patients, a physician financial withhold for referral was associated with fewer mental health referrals. A physician productivity bonus was associated with greater access to mental health specialists. Depressive symptom and restricted activity day outcomes in more-managed health plans and offices were similar to or better than less-managed settings. Patients in more-managed offices had lower ratings of care from their primary physicians. CONCLUSIONS: The intensity of managed care was generally not associated with access to mental health specialists. The small number of managed care strategies associated with reduced access were offset by other strategies associated with increased access. Consequently, no adverse health outcomes were detected, but lower patient ratings of care provided by their primary physicians were found.