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PubMed1999

Psychiatric co-morbidity and hospital utilization in the general medical sector.

BACKGROUND: This article provides evidence about the relationship between psychiatric disorders, physical disorders and hospital use in the general medical sector using a broadly based survey of the US population. METHODS: The data are from the 1989 National Health Interview Survey. This survey contains medical and mental health evaluations for the entire sample. In a multivariate framework, the author estimates the effect of mental illness on the probability of being admitted to a general hospital, the number of admissions and the length of stay. RESULTS: Hospital use in the general medical sector is significantly higher for persons with coexisting physical and psychiatric conditions than for those with no psychiatric disorders. For a wide range of medical conditions, the predicted number of hospital admissions and the length of a hospital stay increase substantially when the physical illness is accompanied by a psychiatric condition. CONCLUSIONS: One implication of this finding is that economic evaluations of alternative psychiatric treatments should consider any differences in hospital costs related to the treatment of coexisting medical conditions. Another implication pertains to health care systems where insurers have some discretion over which individuals to insure. In the absence of adequate adjustments in insurance payments for high-risk potential enrollees, psychiatrically disabled persons may have more limited access to health insurance.

Cross-Sectional Studies↗
PubMed1995

[Social legislative and structural deficits of ambulatory management of chronic psychiatric and handicapped patients].

In the past 25 years, psychiatric care for the chronically mentally ill in Germany has improved steadily. However, has improved steadily. However, this patient group continues to be discriminated against, especially in the sphere of outpatient care. The mentally ill often do not meet the requirements that the respective social security agencies, i.e. in particular pension and health insurance, set out for the granting of benefits. Moreover, contrary to scientific knowledge, measures aimed at the treatment of social disabilities are defined not as psychiatric rehabilitation measures, but as measures of social integration. For these reasons welfare is highly overrepresented in the financing of rehabilitation for the mentally ill. In recent years, legislators have attempted to compensate certain cases of discrimination. Significant legislative changes and administrative developments are described and discussed in terms of their implications.

Ambulatory Care↗
PubMed1994

Private insurance coverage for the treatment of mental illness versus general medical care: a policy of inequity.

Private insurance coverage has historically been and continues to be discriminatory toward patients requiring treatment for mental illness and substance abuse disorders in comparison with those in need of general medical care. Factors contributing to this disparity include stigma, relatively low overt consumer demand for psychiatric care, lack of knowledge about psychiatric illness and treatment on the part of insurers, a historical reliance on public sector psychiatry, and the assumption that more liberal psychiatric benefits result in unnecessary and excessive use. Strategies aimed at eliminating discriminatory insurance practices against those in need of mental health care must be implemented. Recommended approaches include further research on the cost effectiveness of mental health care, public education regarding the nature of mental illness and its treatment, patient/family advocacy, and the marketing of services by mental health professionals.

Cost-Benefit Analysis↗
PubMed1991

Mental health needs of the uninsured.

As many as 37 million Americans have no medical insurance, but no data exist on the mental health needs of community samples of the uninsured. Using interview data from a household sample in Los Angeles, we found that the uninsured had a higher prevalence of serious psychiatric disorder (16%) than those with private health insurance (12%), but had a prevalence similar to those with Medicaid (18%). Access to mental health services among those with a psychiatric disorder was similar in the uninsured (14.5%) and those with private insurance (18%) but was less than those with Medicaid coverage (42%). These results indicate that the uninsured have a great potential need for mental health services and that access might be improved through insurance plans such as Medicaid. However, further study is needed to determine the adequacy and quality of services provided under Medicaid and whether such a plan would improve access for an uninsured population such as the one studied here.

Community Mental Health Services↗
PubMed1994

Characteristics of psychoanalytic patients under a nationalized health plan: DSM-III-R diagnoses, previous treatment, and childhood trauma.

OBJECTIVE: This article reports the results of a survey to collect data on the characteristics of patients in psychoanalysis under a nationalized health insurance scheme. METHOD: A questionnaire, to be answered anonymously, was sent to all 174 accredited psychoanalysts in Ontario, Canada. Part 1 of the questionnaire consisted of 38 questions on the analyst's pattern of practice. Part 2, also to be filled out by the analyst, consisted of 452 questions on the demographic characteristics, childhood traumas, DSM-III-R diagnoses, and indications for psychoanalysis of each of the analyst's patients. RESULTS: One hundred seventeen analysts responded--a survey response rate of 67%--with data on 580 patients. Fifty-nine percent (N = 344) of patients were women, and 41% (N = 236) were men. Eighty-two percent had attempted other forms of treatment, including briefer forms of psychotherapy and medication, prior to psychoanalysis. During childhood, 23% had had traumatic separations, 23% had been sexually abused, 22% had been physically abused, and 21% had had a parent or sibling die. The mean number of adult psychiatric disorders at the beginning of analysis was four, and the mode was two. CONCLUSIONS: In a nationalized health insurance scheme, the psychoanalytic patients were mostly women, they had high rates of trauma and psychopathology, and they had attempted other forms of briefer treatment before resorting to psychoanalysis.

Adolescent↗
PubMed1996

Managed care constraints on psychiatrists' hospital practices: bargaining power and professional autonomy.

OBJECTIVE: The increasing involvement of insurers and hospitals in monitoring patient care is encroaching on the psychiatrist's autonomy in making clinical decisions. This study examined the prevalence of constraints on psychiatric inpatient practices, as well as how characteristics of psychiatrists affect the type and the degree of these external pressures. METHOD: About 2,500 psychiatrists with active hospital affiliations were surveyed by mail, as a subset of APA's 1988 national survey of psychiatrists. They were questioned about whether the hospital or insurers had pressured them to change their inpatient practices or had attempted to discourage admission of certain types of patients. Characteristics of the psychiatrists' background, available from the main survey, were used as independent variables in a set of regression models, with frequency of different constraints as the dependent variables. RESULTS: More than three quarters of those surveyed reported pressure from insurers for early discharge; nearly two-thirds said hospitals limited length of stay; and about half had been discouraged from admitting severely ill patients, the uninsured, or Medicaid recipients. Characteristics of psychiatrists, such as length of time in practice, income, sex, and medical school education outside the United States, were associated with the prevalence of external pressures. CONCLUSIONS: Constraints on psychiatrists' practices are widespread. Their ability to resist pressures depends on their bargaining power, which seems to be lowest for those who have relatively little experience, who are female, or who have gone to medical school outside the United States. Psychiatrists appear to be willing to trade off more constraints for higher incomes. Severely ill patients and those with little or no insurance are more likely than others to be affected by these limits on psychiatrists' autonomy.

Female↗
PubMed2001

A family member's legal experience with an insurer's refusal to recertify inpatient mental health treatment.

My son Nathaniel has bipolar disorder and was hospitalized for 6 months, during which time our insurance company was prepared to refuse certification more than once despite a policy that included 365 days of inpatient mental health treatment. A break in coverage by the insurance company would have meant that Nathaniel, still suicidal, would not receive the life-saving care he needed. Fortunately, I am a lawyer, which enabled me to act as a legal advocate for my son when our insurer threatened not to recertify. Because my son's experience with the insurance company is not unusual--many patients with mental illness struggle with insurance companies who refuse to certify treatment--I believe that the family or support people of seriously ill psychiatric patients should be prepared to act in circumstances similar to mine. Psychiatric inpatient units should, as a matter of course, provide information on legal remedies that can be obtained before irreparable harm occurs.

Bipolar Disorder↗
PubMed1991

National health insurance and private psychiatry.

From 1972-73 to 1988-89, the number of Canadian psychiatrists doubled. Most psychiatrists are in fee-for-service practice. The median earnings of psychiatrists are close to those of internists. There is lack of psychiatric services available, but not a lack of psychiatrists. The lack of services is due largely to the allocation of psychiatric resources. The maldistribution of psychiatrists is increasing as more settle in urban centres. The U.S. General Medical National Advisory Council recommends that psychiatry spend two thirds of clinical time treating severe illnesses such as psychoses. Before any changes are made to the structure of Canadian psychiatry, more data are needed on patterns of fee-for-service practice, the characteristics of patients, the course and outcome of private psychiatric care, and alternative patterns of practice in which psychiatrists are consultants to family physicians and non-medical therapists.

Canada↗
PubMed2005

[Involuntary Hospitalisations in 2000 According to German "PsychKG" in the City of Hannover].

OBJECTIVE: To examine for one year which psychiatric services are involved in involuntary hospitalisations according to PsychKG (German law concerning psychiatric practice) in the City of Hannover. METHOD: All available data within the health administration of the former city and former county of Hannover of compulsory admissions in the year 2000 were evaluated. RESULTS: In 2000, 524 patients were involuntary admitted to psychiatric hospitals according to the data of the health administration of the city of Hannover. The two major diagnoses were schizophrenia or substance addiction of involuntarily admitted patients, most hospitalisation were documented for Fridays, the most frequent time was between 9 and 1 hour p. m. The services in Hannover which dealt most with involuntary admissions were the either physicians of "KV" (Kassenarztliche Vereinigung, the German physicians organisation who is in charge of the treatment of all patients for non-private health insurances) or the physicians of the psychiatric departments of the Hannover Medical School. CONCLUSIONS: The major provider of psychiatric assistence for compulsory admissions within the City of Hannover are the physicians of the KV and the psychiatric departments of the Hannover Medical School.

Catchment Area, Health↗
PubMed1965

PSYCHIATRIC PROGRAMS: THEIR MEDICAL INTEGRATION.

The basic premise that psychiatry and medicine are one and the same discipline is advanced. Patients present with symptoms: sometimes largely the result of structural change, sometimes largely the result of emotional perturbation, but most frequently a mixture of both. The physician can never do his job satisfactorily without attention to the emotional problems of his patient, which is essentially the subject matter of psychiatry. He must have adequate training during his medical school years in order to recognize and handle emotional problems. The psychiatrically oriented general practitioner and the psychiatrist, who live in the community, are most valuable mental health resources and must have treatment facilities in the general hospital. Furthermore, hospital and medical insurance plans must be devised that will not penalize either doctor or patient when mental illness is recognized and dealt with in the most appropriate manner.

Canada↗
PubMed2000

[Are psychiatric illnesses adequately considered in distribution of nursing care levels according to the nursing care insurance law? Evaluation using a new scale for evaluating need for nursing care by senior citizens].

The object of our study is the evaluation of care needs of senior citizens and the adjustment of certain stage of care according to the German Health Care Act ("Pflegeversicherungsgesetz"). For assessment of care needs we developed a new rating scale (BPS). Factor analysis of the rating scale showed 5 dimensions: (1) "Psychoorganic Syndrome" (Dementia), (2) "Physical Care Needs", (3) "Lack of Social Skills", (4) "Aggressiveness" and (5) "Depression". The sample size is N = 1739, mean age 82.5 years. A statistically significant partial correlation of the extent of care needs as indicated by the stage of care described by BPS dimensions was found only for dimension (2) "Physical Care Needs" (r = 0.50). Cluster analysis resulted in distribution of the whole sample into 6 discriminable groups, according to their syndrome specificity (BPS profiles). Additionally clusters are different regarding the severity of need for care. It is obvious, analyzing the adjustment of stages of care within clusters, that psychiatric relevant disturbances contribute substantially to this adjustment. Nevertheless this finding is valid only for aged people, who receive regular care by ambulant or home services, and can not be transferred to senior citizens cared by their families.

Aged↗
PubMed1988

Utilization review of psychiatric care: building a program that works.

Since the early 1970s the federal government, private insurers, and employers have searched for ways to control health care costs. In 1972, Congress, dissatisfied with hospitals' utilization review efforts under the Medicare program created Professional Standards Review Organizations (PSROs). Ten years later when the Medicare reimbursement system underwent radical changes, the utilization review system remained more or less intact but had its name changed to Professional Review Organizations (PROs). The insurance industry has developed and employed, with varying levels of success, several cost-saving tactics, including deductibles and copayments for specialized care, limitation of benefits by diagnosis or facility type, exclusion of specific disorders, inclusion of dollar limits, pre-payment claims review for specific types of service, and post-payment review with retroactive denial of claims. Case management is the latest development in the ever-widening search to put a lid on health care costs. These attempts to measure the effectiveness of care vis a vis the dollar spent for it have been especially difficult for psychiatry, a less measurable science than other fields of medicine. Because psychiatry straddles the disciplines of sociology, psychology, and medicine, it is not easily understood. Inadequate documentation of care, a paucity of outcome studies, and confidentiality issues all combine to make utilization review particularly difficult in psychiatry. This paper will describe a collaboration between Blue Cross and Blue Shield of Maryland and four private psychiatric hospitals in the state that resulted in a workable, effective utilization review program acceptable to providers, payers, and patients.

Adolescent↗
PubMed1992

Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland.

OBJECTIVE: To determine whether uninsured and Medicaid patients have higher rates of avoidable hospitalizations than do insured patients. DESIGN: We used 1987 computerized hospital discharge data to select a cross-sectional sample of hospitalized patients. Population estimates from the Current Population Survey were used to estimate rates of admission, standardized for age and sex. SETTING: Nonfederal acute care hospitals in Massachusetts and Maryland. PATIENTS: All patients under 65 years of age who were uninsured, privately insured, or insured by Medicaid. Hospitalizations for obstetric and psychiatric conditions were excluded. MAIN OUTCOME MEASURES: Relative risk of admission for 12 avoidable hospital conditions (AHCs) identified by a physician panel. RESULTS: Uninsured and Medicaid patients were more likely than insured patients to be hospitalized for AHCs. Rates for uninsured patients were significantly greater than for privately insured patients in Massachusetts for 10 of 12 individual AHCs, and in Maryland for five of 12 AHCs. After adjustment for baseline utilization, the results were statistically significant for 10 of 12 AHCs in Massachusetts and seven of 12 AHCs in Maryland. For Medicaid patients, rates were significantly greater than for privately insured patients for all AHCs in each state before adjustment, and for nine of 12 and seven of 12 AHCs in each state, respectively, after adjustment for baseline utilization. CONCLUSION: Our findings suggest that patients who are uninsured or who have Medicaid coverage have higher rates of hospitalization for conditions that can often be treated out of hospital or avoided altogether. Our approach is potentially useful for routine monitoring of access and quality of care for selected groups of patients.

Adult↗
PubMed2001

Insurance status and length of stay for involuntarily hospitalized patients.

General and private psychiatric hospitals are becoming increasingly common as sites for involuntary hospitalization. Unlike the public facilities that these settings are supplanting, these hospitals must pay strict attention to issues associated with reimbursement, insurance status, and managed care. This article examines the effects of insurance status on length of stay for involuntarily hospitalized patients in general and private hospitals in Massachusetts. Using a two-stage sampling procedure, data on episodes of involuntary hospitalization were gathered and assessed using multiple regression. The primary effect was found between patients with Medicare, who had the longest stays, and individuals who were uninsured, who had the shortest. The data raise concerns that warrant closer scrutiny on the part of administrators and clinicians.

Adult↗
PubMed1993

[Mental illness in patients in primary health care. A Scandinavian multicenter study].

In a Nordic multicentre study of psychiatric illness in primary care, patients in four health districts were screened for psychiatric illness. General practitioners' ratings of psychiatric illness and patients' ratings of psychosocial problems were also included. The patients' utilisation of care and health insurance facilities was reviewed. A random subsample of patients were invited to a semi-structured diagnostic interview with a psychiatrist. Results from the Swedish part of the study showed about 1/3 of the 724 patients investigated to be probable psychiatric cases, while 1/5 were psychiatric cases in need of treatment. The psychiatric cases were characterised by a preponderance of divorced, unemployed women. At 1-year follow up, the utilisation rate of care and health insurance facilities among psychiatric cases was found to be higher than for nonpsychiatric cases.

Adult↗
PubMed1981

Psychotherapy under National Health Insurance: ten years of Canadian experience.

Canadian psychiatrists have worked under National Health Insurance since 1969-1970. The removal of the economic barrier to treatment has produced a system under which practitioners can rationally prescribe treatment for all socioeconomic groups. In particular, long-term psychotherapy is now open, in principle, to all who can benefit from it. Comprehensive coverage of psychiatric care makes clinical sense, but leaves the physician with a serious social responsibility in determining the profile of his practice.

Canada↗
PubMed1982

Suicide and the standard of care: optimal vs. acceptable.

The accepted standard of care in the treatment of suicidal patients is discussed from the perspectives of the law, malpractice insurance claims, the mental health professions, and the ideal. A review of decisions of professional liability in suits for wrongful death provides guidelines for what the court considers to be adequate care. Out of court settlements further connote accepted standards of reasonable care. Although attention to potential malpractice issues is necessary and appropriate, what appear to result are an acceptance of minimal standards and the practice of defensive care. It is argued that by demanding more optimal standards the consequent quality of care not only serves the patient best but provides the best legal protection as well.

Adult↗