Herbert J. Schlesinger

The Effect of Insurance Benefit Changes on Use of Child and Adolescent Outpatient Mental Health Services

Use of outpatient mental health services by dependent children younger than 18 years of age enrolled in the Blue Cross and Blue Shield Federal Employees Plan (FEP) is examined in 1978 and 1983 focusing on a cut in benefits and a shift from high- to low-option plan enrollment between those years. While use rates increased from 2.13% to 2.76% by 1983, the average number of visits decreased from 18.9 to 12.8. High-option plan use exceeded low-option plan use in both years—2.26% versus 0.81% in 1978 and 3.58% versus 1.93% in 1983. In addition to benefit plan, ethnicity, parents education, type of provider, and type of treatment setting also significantly predicted amount of use. Despite the strong evidence of the effects of benefit coverage, it is likely that need exceeded use even in this insured population of children and adolescents. Implications of the findings are discussed in the context of recent dramatic changes in mental service delivery including privatization, managed care initiatives to cut costs, and growing pressures for national health insurance.

Women and outpatient mental health services: use by black, Hispanic, and white women in a national insured population.

Factors affecting ethnic differences in women’s use of outpatient mental health services were analyzed to determine whether lower use by black and Hispanic women occurred when socioeconomic and other factors are controlled. Employing the Andersen and Newman model of health use, insurance claims of 1.2 million federal employees insured by Blue Cross/Blue Shield in 1983 were analyzed to identify significant predictors of use. Results revealed that black and Hispanic women had lower probabilities and amounts of use when compared to white women even after controlling for a number of variables. Further research is needed to examine cultural and gender-related factors that may underlie ethnic differences; attitudinal factors and service system barriers are also implicated. Such findings have policy implications in the current climate of health care reform for which efforts are needed to increase access to care for ethnic minority women and other underserved populations.

Use of Inpatient Services by a National Population: Do Benefits Make a Difference?

This study describes changes in the use of inpatient mental health services by children and adolescents under age 18. The data were insurance claims from the Blue Cross and Blue Shield Federal Employees Program. The study focused on a cut in inpatient benefits that occurred between 1978 and 1983. The rate of inpatient hospitalization dropped significantly, and the average number of days also decreased significantly from 45.8 to 27.0 days. This study is among the first to demonstrate that the rate and amount of inpatient care provided for children and adolescents is responsive to variations in benefit coverage.

Does managing behavioral health care services increase the cost of providing medical care

This study examined the possibility that managing behavioral health care services achieves savings by cost shifting—by denying care or impeding access to care—and in that way encouraging patients to seek needed behavioral health care in the medical care system. In 1993, a large industrial company carved out employee behavioral health care from its unmanaged, indemnity medical care benefits and offered employees an enhanced benefit package through a managed behavioral health care company. This study compared the use and cost of behavioral health care and medical care services for two years before the carve-out and for three years afterward. The rate of behavioral health care usage remained the same or increased after the carve-out, while the cost of providing the care decreased. Controlling for trends that began before the inception of managed behavioral health, medical care costs decreased for those using behavioral health care services. No evidence supporting cost shifting was found.

Assessing consumer benefit: Cost offset as an incidental effect of psychotherapy

In addition to improved quality of care, evidence of cost benefits associated with the provision of consultation-liaison services may be used to justify the expenses of such programs. Reductions in use of medical services following mental health treatments are not inevitable, however. Advocates of C-L should be aware of the circumstances under which cost benefits are likely to be found and focus assessments appropriately.

Serious physical illness as a stressor: Effects on family use of medical services.

The purpose of this study was to investigate the effect of stress on the family due to the hospitalization of a family member for a serious chronic illness. The data were the health insurance claims of 3,591 families obtained from the largest U.S.A. insurer of federal employees. It was hypothesized that the nonhospitalized family members would have a stress-related increase in medical expenses for some period of time after the chronically ill person was hospitalized. Multiple regression analysis with adjustments for a number of covariates found increases in mean medical charges of

The process of interpretation and the moment of change

326 per person (p less than 0.01) (excluding the hospitalized person) in the 3 years following the hospitalization. This finding lends support to the theory that stress--in this case, hospitalization of one family member--affects the entire family system. No significant differences were found in medical charges between families who did and did not receive mental health treatment following the hospitalization.

When Words Are Not Enough

The effectiveness of analytic Interpretation is conditioned by a number of factors within the patient. within the analyst, and within the analytic situation. I will focus on one of these factors, part of the technical activity of the analyst that I will call follow-up interpretation, one which omitted, or even slighted, sharply diminishes the effectiveness of interpretation.

Linking physical and mental health: Comparing users and non-users of mental health services in medical care utilization

124  Dr. Schlesinger is Alfred J. and Monette C. Marrow Professor of Psychology, Emeritus, New School for Social Research; Training and Supervising Analyst, Columbia University Centre for Psychoanalytic Training and Research. Dr. Appelbaum is Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons; Instructor, Columbia University Centre for Psychoanalytic Training and Research. 1 John 20:17 2 Luke 6:19 Touch me not; for I am not yet ascended to my Father. 1

A new look at evidence about reduced cost of medical utilization following mental health treatment.

Higher medical costs incurred by persons with mental disorders was assessed by comparing users and non-users of mental health services in their use of medical (non-mental health) services. Insurance claims data for 4.8 million persons enrolled in the Federal Employees Plan in 1978 were examined. Policy-related recommendations include the need for coordinated mental and physical health care in primary care settings. In particular, the physical health problems of patients in mental health settings should not be ignored as these may cause or exacerbate distress and reduce the effectiveness of mental health treatment.