Colleen L. Barry

Obesity Metaphors: How Beliefs about the Causes of Obesity Affect Support for Public Policy

CONTEXTnRelatively little is known about the factors shaping public attitudes toward obesity as a policy concern. This study examines whether individuals beliefs about the causes of obesity affect their support for policies aimed at stemming obesity rates. This article identifies a unique role of metaphor-based beliefs, as distinct from conventional political attitudes, in explaining support for obesity policies.nnnMETHODSnThis article used the Yale Rudd Center Public Opinion on Obesity Survey, a nationally representative web sample surveyed from the Knowledge Networks panel in 2006/07 (N = 1,009). The study examines how respondents demographic and health characteristics, political attitudes, and agreement with seven obesity metaphors affect support for sixteen policies to reduce obesity rates.nnnFINDINGSnIncluding obesity metaphors in regression models helps explain public support for policies to curb obesity beyond levels attributable solely to demographic, health, and political characteristics. The metaphors that people use to understand rising obesity rates are strong predictors of support for public policy, and their influence varies across different types of policy interventions.nnnCONCLUSIONSnOver the last five years, the United States has begun to grapple with the implications of dramatically escalating rates of obesity. Individuals use metaphors to better understand increasing rates of obesity, and obesity metaphors are independent and powerful predictors of support for public policies to curb obesity. Metaphorical reasoning also offers a potential framework for using strategic issue framing to shift support for obesity policies.

Antidepressants and suicide risk: how did specific information in FDA safety warnings affect treatment patterns?

OBJECTIVEnFrom June 2003 through October 2004, the U.S. Food and Drug Administration (FDA) released five safety warnings related to antidepressant use and the increased risk of suicidality for children. Although researchers have documented a decline in antidepressant use among children over this period, less is known about whether specific safety information conveyed in individual warnings was reflected in treatment patterns.nnnMETHODSnThomson Reuters MarketScan claims data (2001-2005) for a national sample of privately insured children were used to construct treatment episodes (N=22,689). For each new episode of major depressive disorder, it was determined whether treatment followed specific recommendations included in warnings released by the FDA. Treatment recommendations pertained to the use of the antidepressants paroxetine and fluoxetine and to patient monitoring. Treatment patterns were expected to change as the risk information conveyed by the FDA changed over time.nnnRESULTSnThe timing of FDA recommendations was associated with trends in the use of paroxetine and fluoxetine by children with major depressive disorder who were initiating antidepressant treatment. However, no evidence of increases in outpatient visits (indicative of monitoring) among depressed children initiating antidepressant use was found.nnnCONCLUSIONSnRelease of specific risk and benefit information by the FDA was associated with changes in prescribing but not in outpatient follow-up. These results suggest that the FDA plays an important role in communicating information to the public and providers. Yet, although public health safety warnings were associated with changes in some practice patterns, not all recommendations conveyed in warnings were followed.

Impact of full mental health and substance abuse parity for children in the Federal Employees Health Benefits Program.

OBJECTIVE. The Federal Employees Health Benefits Program implemented full mental health and substance abuse parity in January 2001. Evaluation of this policy revealed that parity increased adult beneficiaries’ financial protection by lowering mental health and substance abuse out-of-pocket costs for service users in most plans studied but did not increase rates of service use or spending among adult service users. This study examined the effects of full mental health and substance abuse parity for children. METHODS. Employing a quasiexperimental design, we compared children in 7 Federal Employees Health Benefits plans from 1999 to 2002 with children in a matched set of plans that did not have a comparable change in mental health and substance abuse coverage. Using a difference-in-differences analysis, we examined the likelihood of child mental health and substance abuse service use, total spending among child service users, and out-of-pocket spending. RESULTS. The apparent increase in the rate of children’s mental health and substance abuse service use after implementation of parity was almost entirely due to secular trends of increased service utilization. Estimates for children’s mental health and substance abuse spending conditional on this service use showed significant decreases in spending per user attributable to parity for 2 plans; spending estimates for the other plans were not statistically significant. Children using these services in 3 of 7 plans experienced statistically significant reductions in out-of-pocket spending attributable to the parity policy, and the average dollar savings was sizeable for users in those 3 plans. In the remaining 4 plans, out-of-pocket spending also decreased, but these decreases were not statistically significant. CONCLUSIONS. Full mental health and substance abuse parity for children, within the context of managed care, can achieve equivalence of benefits in health insurance coverage and improve financial protection without adversely affecting health care costs but may not expand access for children who need these services.

Interdisciplinary staffing patterns: do for-profit and nonprofit hospices differ?

BACKGROUNDnInterdisciplinary care is fundamental to the hospice philosophy and is a key component of high-quality hospice care. However, little is known about how hospices differ in their interdisciplinary staffing patterns, particularly across nonprofit and for-profit hospices. The purpose of this study was to examine potential differences in the staffing patterns of for-profit and nonprofit hospices.nnnSUBJECTS AND DESIGNnUsing the 2006 Medicare Provider of Services (POS) survey, we conducted a cross-sectional analysis of staffing patterns within Medicare-certified hospices operating in the United States in 2006. In bivariate and multivariable analyses, we examined differences in staffing patterns measured by the existence of a full range of interdisciplinary staff (defined as having at least 1 full-time equivalent (FTE) staff in each of 4 disciplines ascertained by the survey: physician, nursing, psychosocial, and home health aide) and by the professional mix of staff within each discipline.nnnRESULTSnFor-profit hospices had a winder range of paid staff but there were no differences by ownerships when volunteer staff were included. For-profit hospices had significantly fewer registered nurse FTEs as a proportion of nursing staff, fewer medical social worker FTEs as a proportion of psychosocial staff, and fewer clinician FTEs as a proportion of total staff (p values <0.05). Compared to nonprofit hospices, for-profit and government-owned hospices also used proportionally fewer volunteer FTEs.nnnCONCLUSIONSnHospice staffing patterns differed significantly by ownership type. Future research should evaluate the impact of these differences on quality of care and satisfaction among patients and families using hospice.

Pediatric antidepressant use after the black-box warning

In 2004 the Food and Drug Administration (FDA) required a black-box warning on antidepressants that describes a possible suicide risk in children. An analysis of the events, evidence, and FDA actions reveals information asymmetries that affect various players ability to identify and act on risks. Antidepressant use declined sharply overall, not just among children, and the FDAs emphasis on the proven efficacy of fluoxetine (generic Prozac) did not prompt dramatic shifts in prescribing. We conclude that risk communication strategies need to be refined, to ensure intended results.

News coverage of FDA warnings on pediatric antidepressant use and suicidality.

OBJECTIVE: In 2004, after an 18-month investigation, the Food and Drug Administration (FDA) directed pharmaceutical manufacturers to add a black box warning to antidepressants regarding increased risk of suicidality in children. Our objective was to evaluate the quality and content of and overall impression conveyed in news coverage of this issue. METHODS: We collected all news stories on pediatric antidepressant use and suicidality published in a convenience sample of 10 of the highest-circulation print newspapers in the United States, the 3 major television networks, and a major cable news network in 2003 and 2004 (N = 167). Two researchers coded news articles by using a 9-item instrument. RESULTS: The quality of news reporting on key health messages included in FDA warnings was mixed. The overwhelming majority of news stories correctly described a risk of suicidality associated with pediatric antidepressant use, as opposed to suicide itself. However, other key health messages highlighted in FDA warnings often were absent from news coverage. News stories were more likely to include anecdotes of children harmed versus children helped by antidepressants, whereas expert sources quoted were more likely to emphasize the benefits of antidepressants over their risks. However, the majority of news stories conveyed neither the overall impression that the risks of pediatric antidepressant use outweighed the benefits nor the impression that the benefits outweighed the risks, and coverage became increasingly neutral over time. CONCLUSIONS: Inclusion of key health messages in FDA safety warnings was not sufficient to ensure their communication to the public through the lay press.

Does Private Insurance Adequately Protect Families of Children With Mental Health Disorders

OBJECTIVE: Although private insurance typically covers many health care costs, the challenges faced by families who care for a sick child are substantial. These challenges may be more severe for children with special health care needs (CSHCN) with mental illnesses than for other CSHCN. Our objective was to determine if families of privately insured children who need mental health care face different burdens than other families in caring for their children. PATIENTS AND METHODS: We used the 2005–2006 National Survey of Children With Special Health Care Needs (NS-CSHCN) to study privately insured children aged 6 to 17 years. We compared CSHCN with mental health care needs (N = 4918) to 3 groups: children with no special health care needs (n = 2346); CSHCN with no mental health care needs (n = 16250); and CSHCN with no mental health care need but a need for other specialty services (n = 7902). The latter group was a subset of CSHCN with no mental health care need. We used weighted logistic regression and study outcomes across 4 domains: financial burden; health plan experiences; labor-market and time effects; and parent experience with services. RESULTS: We found that families of children with mental health care needs face significantly greater financial barriers, have more negative health plan experiences, and are more likely to reduce their labor-market participation to care for their child than other families. CONCLUSIONS: Families of privately insured CSHCN who need mental health care face a higher burden than other families in caring for their children. Policies are needed to help these families obtain affordable, high-quality care for their children.

New Evidence on the Effects of State Mental Health Mandates

State mental health parity laws improve equity in private insurance coverage for mental and physical health services, but prior research shows no effect on service use. We study whether state parity differentially affects individuals by employer size since large firms are often exempt from state health mandates due to the Employee Retirement Income Security Act. We also examine whether state parity laws differentially affect use among individuals with low incomes or in poor mental health. We find that individuals in smaller firms are more likely to use services post-parity implementation and that this effect is concentrated among low-income individuals.

Realigning Clinical and Economic Incentives to Support Depression Management Within a Medicaid Population: The Colorado Access Experience

The authors describe their experiences in developing an economically sustainable depression care management program within Colorado Access, a non-profit Medicaid health plan. They describe high rates of mental health issues, medical comorbidities, and psychosocial barriers to care within the plan’s Medicaid population. They discuss how the company redirected resources to incorporate depression care management into an intensive care management program focused on high-cost members with multiple chronic medical conditions. This strategy allowed Colorado Access to cost effectively care manage a targeted group of high-cost Medicaid recipients across multiple primary care physician (PCP) practices without requiring changes in provider workflow.

The Political Evolution of Mental Health Parity

&NA; This article traces the evolution of the mental health parity debate in American politics, with a focus on how interest groups and politicians have attempted to influence perceptions about treatment effectiveness and the cost of benefit expansion. When parity laws are in place, they require health plans operating in the private health insurance market to provide an equivalent level of coverage for mental health and general medical care. Business and insurance industry groups oppose parity due to cost concerns. The mental health community has framed parity as an antidiscrimination measure that would achieve greater insurance equity across disease groups. The role of personal experience with mental illness among lawmakers and others in framing the parity debate is also considered.