Robert A. Dorwart

The influence of psychiatric disorders on patients' ratings of satisfaction with health care.

OBJECTIVES Patient ratings of satisfaction with health care have been used by patients, insurers, and employers seeking data to compare the quality of health plans and systems of care. Concerns with these ratings include their subjective nature and potential for being influenced by patient characteristics unrelated to the quality of their care. The authors examined the influence of an active psychiatric disorder on patient satisfaction with health care, hypothesizing that patients with psychiatric disorders would be less satisfied with their health care, due to the adverse effects of these conditions on mood and cognition. METHODS The authors used linked claims and survey data from the 1991 Medicare Current Beneficiary Survey. Using logistic regressions that controlled for patient sociodemographic and clinical characteristics, the authors examined the influence of an active psychiatric disorder on satisfaction with overall quality of health care and with specific dimensions of quality. The authors also examined the effects of specific types of psychiatric disorders. RESULTS Aged and disabled beneficiaries with psychiatric disorders were significantly less likely than those without disorders to be satisfied with the overall quality of health care, follow-up care, and the physicians concern for their overall health. Disabled beneficiaries were also less likely to be satisfied with the health information provided. Further variation was found by type of psychiatric disorder. CONCLUSIONS One interpretation of these findings is that Medicare beneficiaries with psychiatric disorders receive lower quality care, a possibility that warrants further investigation. Alternatively, patients with psychiatric disorders may report lower satisfaction despite receiving comparable health care; this interpretation points toward the need for casemix adjustment when comparing satisfaction ratings across health plans and the development of quality measures less susceptible to subjective biases.

COMPETITION, OWNERSHIP, AND ACCESS TO HOSPITAL SERVICES : EVIDENCE FROM PSYCHIATRIC HOSPITALS

OBJECTIVES This article examines the impact of increasing competition among hospitals on access to inpatient services and preexisting differences in access between nonprofit and for-profit facilities. It tests theoretical propositions that suggest that nonprofit and for-profit hospitals will respond in different ways and to differing degrees to changing competitive pressures. METHODS Drawing data from a 1987-88 national survey of psychiatric hospitals, the authors measured access in terms of the availability of different types of services and the provision of uncompensated care. The impact of hospital ownership, competition as well as the interaction of ownership and competition was assessed through a set of regression models, controlling for other characteristics of the hospital markets and local service system. RESULTS Nonprofit psychiatric hospitals provide greater access than their for-profit counterparts under conditions of limited competition. Increased competition reduces the ownership-related differences in uncompensated care, but increases the differences for marginally profitable services. The market share of for-profit hospitals had an independent negative effect on access, holding constant the intensity of competition. CONCLUSIONS The interaction of ownership and competition explains some seemingly inconsistent finding in the literature and points to the complexity of relying on ownership-based policies to protect access in an increasingly competitive health-care system.

Schizophrenia and the life cycle.

We reframe the longitudinal treatment of persons with schizophrenia from the perspective of phases in adult development. This approach articulates the need for different interventions of varying intensities over the persons lifetime. The paper discusses the implications of an adult developmental perspective in managing pharmacologic treatment and psychosocial interventions, and in reallocating financial resources for improved long-term outcomes. This perspective is especially useful in the context of a comprehensive community mental health program permitting access to a continuum of services throughout the lifecycle.

Competition and Community Mental Health Agencies

Community mental health agencies (CMHAs) provide most of the institutional outpatient treatment in the United States. A great deal of this care is given to clients at prices below the actual cost of the service. As the number of mental health providers increases, the question of how competition shapes the performance of CMHAs becomes more important. We use a two-stage least-squares model to examine how competition from other outpatient facilities, psychiatrists, and health maintenance organizations (HMOs), coupled with demographic, economic, and organizational factors affects subsidized care in CMHAs. Our analysis shows that competition from psychiatrists and HMOs reduces the number of subsidized visits that CMHAs provide and that agencies in urban areas and those initiated with federal funds provide more subsidized care. By restricting access to outpatient treatment, competition may have adverse long-term consequences for potential clients and for state mental health authorities.

Issues in psychiatric hospital care

Private psychiatric hospital care continues to grow despite pressures on hospitals both to keep beds filled and to manage care cost effectively. Budget cuts continue to plague public programs and private hospitals have limited ability to respond to care of the seriously mentally ill. Adding to the problem of providing quality care to all who need it are managed care and utilization review, mandated by insurers, who more often are concerned with controlling costs than with ensuring quality of care. In the 1990s, subspecialization appears to be a significant evolving trend in psychiatric hospital care.

A Comparison of Public and Privatized Approaches to Managed Behavioral Health Care for Persons with Serious Mental Illness

This article compares public and privatized approaches to managed behavioral health care for persons with serious mental illness in Massachusetts. Data from the Department of Mental Health (DMH) for 247 patients receiving care managed by DMH and 312 in a Medicaid carve-out were compared. Repeated measures multivariate analysis of variance models were used to examine adjusted changes in number of admissions, bed days, and facilities used from a baseline year before program implementation in 1992 through two follow-up years. Results were comparable for the two programs with similar reductions in the number of people receiving inpatient care but increases in admissions and bed days. Possible problems with continuity of care, indicated by individuals using multiple facilities, were identified for both. Given the evidence of comparable results, the choice between the two approaches is likely to be dictated by various pragmatic and subjective factors other than their demonstrated effectiveness.

Evaluating State Mental Health Care Reform: The Case of Privatization of State Mental Services in Massachusetts

The collapse of the national health care reform initiative in 1994 marked a lost opportunity for all Americans, but especially for those with chronic conditions who face catastrophic medical costs under the present system. Of all the chronic conditions, serious and persistent mental illness (SPMI) presents the strongest case for reform, because the mentally ill are the most vulnerable to the devastating medical, social, and financial consequences of their illness (Sharfstein & Stoline, 1992). With no further federal initiative on the horizon, the question of how to finance services for the SPMI is now one of the most pressing “inescapable decisions” of health care reform (Mechanic, 1994).

Managed mental health: From cost containment to quality assurance

Mental health utilization review is known in the managed care industry to be an effective cost containment product; however, its capacity to monitor and improve quality has yet to be studied (American Psychiatric Association [APA], March 1990). This paper presents the evolution of a comprehensive managed care approach of one national managed health care company over the past five years, with emphasis on the integration of quality assurance into utilization review and other managed care products. Aggregate data describing mental health admissions, available from the utilization review records for a population of 2.9 million covered lives are presented. Implications of the data for insureds, insurers, and providers are discussed. An evolving data base on quality care issues is described along

Clinical and Community-Service Activities of Psychiatric Teaching Hospitals

Because funding for teaching hospitals is threatened in the cost-conscious era of managed care, teaching hospitals must demonstrate their value. To examine the clinical and community-service activities of teaching hospitals, this study compared academic medical centers (AMCs) and other hospitals operating psychiatric residency programs with nonteaching hospitals. Data for the study are from the National Mental Health Facilities Survey, a national survey of providers of inpatient psychiatric care in the United States conducted at the beginning of the current managed care era. When compared with nonteaching hospitals, both types of teaching hospitals offered a larger number of specialized services and had a higher psychiatrist-to-patient ratio. The AMCs received a higher proportion of their revenues from Medicaid than did the nonteaching hospitals. Other teaching hospitals collected a lower percentage of their inpatient charges than the nonteaching hospitals. This study supports the notion that psychiatric teaching hospitals provided more care to low-income and underinsured persons than the nonteaching hospitals and that they offer more services and more psychiatric oversight. The authors find justification for supporting psychiatric teaching hospitals for their clinical and community-service activities.

Health-Care Reform in the States

Although national health reform failed politically in 1994, state reforms, which include many of the issues debated nationally, are being developed, legislated, and carried out. In fact, every state has at least contemplated some variety of health-care reform.’ Naturally, not all states are pushing for the same degree or pace of change. The span extends from reforms that have created near-universal coverage to those with only the most minute modifications. Distinguishing between reforms that affect only mental health services and those that impinge upon the entire health system is becoming more difficult as mental health services gain greater parity with, and integration into, the general health-care system. Therefore, we will mention the federal proposals and discuss the state reforms as they relate to the entire health system, noting particular features of the programs that affect mental health services. We will also talk about one of the most significant types of statelevel health reform, Medicaid managed care, paying particular attention to how mental health services are affected.