Susan D. Hosek

MENTAL HEALTH AND SELECTION OF PREFERRED PROVIDERS : EXPERIENCE IN THREE EMPLOYEE GROUPS

While Preferred Provider Organizations (PPOs) are designed to contain the costs of health care, they may not be able to do so if sicker individuals opt not to use PPO providers. This study examined how level of mental health status and prior use of mental health services affected the decision to use or not use PPO providers for mental health care for employees enrolled in fee-for-service plans with a PPO option. Data were obtained from an employee survey and claims data on three large employee groups. It was not possible to examine effects of sickliness on the intent to select PPO providers for mental health care directly because about one half of employees could not identify who they would visit for mental health care or even how they would select a provider for such care. The intent to use PPO or non-PPO providers for general medical care, however, was not significantly associated with mental health status when other factors were controlled. Furthermore, among persons who used mental health services after implementation of the PPO option, those who had previously visited providers who were to become part of the PPO panel tended to stay with PPO providers, while those who previously visited providers who were not to enter the PPO panel subsequently selected away from PPO providers for mental health care. This pattern of results suggests that established individual patient-provider relationships, rather than sickliness, determined the selection of PPO versus non-PPO providers for mental health care for employees enrolled in these optional PPO fee-for-service plans.

The Effects of Preferred Provider Options in Fee-for-Service Plans on Use of Outpatient Mental Health Services by Three Employee Groups

Descriptions of how preferred provider organizations (PPOs), offered as options to employees enrolled in fee-for-service plans, affected use of outpatient mental health services are provided. Data are from the RAND Preferred Provider Organization Study, which has a sample of employees who enrolled in fee-for-service plans 1 year before and 2 years after a PPO option was offered by three employers in two U.S. sites. To study effects of the optional PPOs on access to mental health care, usage patterns among those who initially stated that they did or did not intend to use PPO providers were examined. By the end of the second post-PPO year, employees had a similar annual probability of having an outpatient mental health visit whether or not they initially intended to use PPO providers. However, during the first post-PPO year, there was a decrease in the probability of use for those initially intending to use PPO providers, relative to those who did not intend to do so, among employees who had no regular medical provider. To study effects of the PPO option on usage levels of mental health care services, users of mental health services who primarily visited PPO were compared with those who primarily visited non-PPO providers. Users who visited PPO providers had significantly lower levels of use, controlling for other factors, than those who primarily visited non-PPO providers. Therefore, despite lower cost sharing for services received from PPO providers, the PPO option appeared to lower outpatient mental health care costs while having no more than a transient effect on access. This study did not evaluate mental health outcomes.

Using DRGs to pay for inpatient substance abuse services: an assessment of the CHAMPUS reimbursement system.

In October 1988, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) introduced a prospective payment system based on diagnostic- related groups (DRGs) to pay for substance abuse services. These services were initially excluded from the new payment system because of concerns that a DRG-based system may have a large and poorly understood financial impact on individual hospitals. This report assesses the performance of a DRG system in explaining variation in costs at the individual patient level and evaluates how well this payment system predicts resource use across hospitals. Overall, the substance abuse DRGs explained only 4.2% of the total variance in charges. It was found that the Medicare DRG-based system had to be modified to reflect the characteristics of the younger CHAMPUS population by splitting DRG 435 to account for the increased costliness of beneficiaries younger than 21 years. In addition, the study revealed substantial variation in the impact of the DRG system on hospital revenue. These differences largely reflected significant differences between general and specialty hospitals.

Physician's Extenders' Performance in Air Force Clinics

We evaluated the quality of care of physicians extenders (PEs: 23 physicians assistants, 7 primary care nurse practitioners) in Air Force primary medicine clinics, as part of an evaluation of PEs assuming a considerable portion of the care formerly provided by physicians in the military medical system. Physicians assistants performed at least as well as physicians on 25 out of 28 nonredundant process–of–care criteria; nurse practitioners met the physicians standard on 14 of 19 criteria. In a comparison of physicians assistants with nurse practitioners, the two groups performance was not significantly different. No major differences were found in PEs and physicians use of ancillary services (laboratory, x–ray, physical therapy) or orders for further care. As expected, PEs consulted physicians infrequently, but more often for serious complaints and at rates similar to those found in a civilian HMO setting. We conclude that the Air Force can deliver the same quality of care when PEs treat a sizable proportion of patients formerly treated by physicians.

Quality of Life Programs

Monthly support group at the ShileyMarcos ADRC for individuals who are in the early stages of Alzheimer’s or a related disorder and started experiencing symptoms before age 65. Four-session photography and book making workshop developed by the Museum of Photographic Arts (MOPA) offered twice a year to participants with memory disorders and their care partners. This program is offered in English and Spanish.