A Proposed Study

Client Improvement and Disposition upon Termination from Outpatient Mental Health Clinics: Impacts of Cultural Factors and Health Insurance upon Psychotherapy and Medication Treatment

Richard Benoit Francoeur, Ph.D.

Client Improvement and Disposition upon Termination from Outpatient Mental Health Clinics: Impacts of Cultural Factors and Health Insurance upon, Psychotherapy and Medication Treatment is a proposed study. It will assess whether cultural factors exacerbate the extent that type of health insurance predisposes certain clients from improving during medication treatment, which may be linked to unaffordable out-of-pocket drug costs or a desire for greater access to psychotherapy.

During 1993-1998, antidepressants fell within the top four categories of all drugs in terms of cost increases (McGinley, 1999). At the outpatient mental health clinics operated by the Jewish Board of Family and Children’s Services (JBFCS), reimbursement rates across all payers for twenty-minute medication visits are much higher than for one-hour psychotherapy visits. This difference suggests that there may be incentives for medication treatment regardless of whether clients are insured for psychiatric medications or can afford the out-of-pocket costs. A similar concern regards the potential for substituting medication treatment when psychotherapy may be more efficacious, cost-effective, and/or preferred by clients.

These two concerns are of increased significance, considering the continuing rise of expenses at these outpatient mental health clinics, despite the peaking of managed care and Medicaid reimbursement rates. In recent years, the mental health reimbursement system has begun moving towards a system of annual capitation (e.g., $5,000 per client). This system of limited total reimbursement provides strong incentives for agencies to adopt cost-effective clinical practices and medication management. In this changing fiscal environment clients who do not comply with medication treatment demands, because of unaffordable out-of-pocket prescription costs or a desire for greater access to psychotherapy, may generate excessive financial costs for the agency. In addition to issues of financial burden, cultural factors such as ethnicity and socioeconomic status may impede client improvement or compliance with care.

Thus for some cultural subgroups of clients, with particular types of health insurance and DSM-IV diagnoses, an increase in the number and/or proportion of psychotherapy visits might lead to cost-effective improvement in client condition and disposition at treatment termination. Alternatively, these effects may either generalize across cultural subgroups or occur within specific subgroups regardless of the number and/or proportion of psychotherapy visits. Cultural factors might exacerbate the effects of financial burden to clients. Within some Hispanic communities, for example, access to indigenous remedies and faith-based healing and/or the disproportionate lack of insurance (Kilborn, 1999) might result in resistance to co-payments and out-of-pocket costs even when insured clients can afford them.

The Proposed Study

The proposed study will be an analysis of program monitoring data from fiscal year 1997-98 for three JBFCS outpatient mental health clinics. The analyses will focus upon specific DSM-IV diagnoses for singular and comorbid depression and anxiety. Findings should yield insights for treatment monitoring and program planning for particular client subgroups, based upon cultural factors (gender, ethnicity, age, household composition, and income source); type of health insurance; and psychotherapy and medication treatment (frequency of each type of visit, duration of overall treatment episode).

Human service agencies frequently contend with incomplete and imperfect program monitoring data. It is unlikely that the data used in the proposed study will capture all of the important predictive factors. To tease out predictive factors, this study will use a unique and promising statistical approach that adjusts for unmeasured factors during the simultaneous estimation of a set of contingent, highly associated predictive equations based upon the same measured factors. The first equation predicts client condition at treatment termination (i.e., deteriorated, unchanged or indeterminate, improved), while the second equation predicts client disposition at termination (i.e., withdrew, completed care, referred to other continuing care). The proposed study will be a demonstration of this innovative, practical approach for program monitoring/evaluation within a major human services agency.

Exploratory analyses will be conducted and explanatory hypotheses will also be tested when warranted. For cultural subgroups of clients receiving only medication treatment, it is hypothesized that HMO clients--who do not incur out of pocket prescription costs--are more likely than other clients to complete contracted care in improved condition. For cultural subgroups of clients receiving both medication and psychotherapy treatment, it is hypothesized that more frequent psychotherapy visits and lower proportions of medication-to-psychotherapy visits predict positive outcomes (i.e., clients completing care in improved condition), beyond what may be predicted from the number of visits for medication management. Significantly higher effects for non-HMO clients, in comparison to those for HMO clients, who incur out-of-pocket prescription costs would signal that increases in psychotherapy visits and decreases in the proportions of medication-to-psychotherapy visits appear more effective for them. For these non-HMO clients, psychotherapy may substitute for medication visits associated with unaffordable prescriptions and/or may counteract the reduced effectiveness of medication visits already incurred.

To complement the focus upon predictions of positive and negative outcomes, it is important to determine whether type of health insurance predicts the frequencies of psychotherapy and medication visits, as well as the duration of the treatment episode. It is hypothesized that HMO and Medicaid clients—who do not incur out-of-pocket prescription costs—tend to incur more medication visits, fewer psychotherapy visits, a higher proportion of medication-to-psychotherapy visits, and shorter psychotherapy treatment episodes than other clients. The proposed study will determine if these hypotheses, tested for women in the National Ambulatory Medical Survey (1990-94) (Glied, 1997), are robust among cultural subgroups of women, as well as men, within the three JBFCS outpatient mental health clinics, characterized as are many other clinics, by unstable economic and organizational factors that influence treatment decisions.

The principal investigator of this proposed study is Richard Benoit Francoeur, Ph.D.

References

Glied, S. (1997). The treatment of women with mental health disorders under HMO and fee-for-service insurance. Women & Health, 26(2), 1-16.

Kilborn, P. T. (1999, April 9). Third of Hispanic Americans do without health coverage. New York Times on the Web.

McGinley, L. (1999, July 7). Heavy advertisement is cited in rapid rise of drug costs. The Wall Street Journal, B6.