Ettner S L, Hermann R C, Tang H
UCLA Dept. of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, CA 90095, USA.
Health Serv Res. 1999 Aug;34(3):737-60.
To examine differences between the general medical and mental health specialty sectors in the expenditure and treatment patterns of aged and disabled Medicare beneficiaries with a physician diagnosis of psychiatric disorder.
Based on 1991-1993 Medicare Current Beneficiary Survey data, linked to the beneficiary's claims and area-level data on provider supply from the Area Resources File and the American Psychological Association.
Outcomes examined included the number of psychiatric services received, psychiatric and total Medicare expenditures, the type of services received, whether or not the patient was hospitalized for a psychiatric disorder, the length of the psychiatric care episode, the intensity of service use, and satisfaction with care. We compared these outcomes for beneficiaries who did and did not receive mental health specialty services during the episode, using multiple regression analyses to adjust for observable population differences. We also performed sensitivity analyses using instrumental variables techniques to reduce the potential bias arising from unmeasured differences in patient case mix across sectors.
Relative to beneficiaries treated only in the general medical sector, those seen by a mental health specialist had longer episodes of care, were more likely to receive services specific to psychiatry, and had greater psychiatric and total expenditures. Among the elderly persons, the higher costs were due to a combination of longer episodes and greater intensity; among the persons who were disabled, they were due primarily to longer episodes. Some evidence was also found of higher satisfaction with care among the disabled individuals treated in the specialty sector. However, evidence of differences in psychiatric hospitalization rates was weaker.
Mental health care provided to Medicare beneficiaries in the general medical sector does not appear to substitute perfectly for care provided in the specialty sector. Our study suggests that the treatment patterns in the specialty sector may be preferred by some patients; further, earlier findings indicate geographic barriers to obtaining specialty care. Thus, the matching of service use to clinical need among this vulnerable population may be inappropriate. The need for further research on outcomes is indicated.
研究患有精神疾病且经医生诊断的老年及残疾医疗保险受益人的支出和治疗模式在普通医疗和心理健康专科领域之间的差异。
基于1991 - 1993年医疗保险当前受益人调查数据，与受益人的索赔数据以及来自区域资源文件和美国心理协会的提供者供应区域层面数据相关联。
所考察的结果包括接受的精神科服务数量、精神科和医疗保险总支出、接受的服务类型、患者是否因精神疾病住院、精神科护理疗程时长、服务使用强度以及护理满意度。我们比较了在此期间接受和未接受心理健康专科服务的受益人的这些结果，使用多元回归分析来调整可观察到的人群差异。我们还使用工具变量技术进行敏感性分析，以减少因各领域患者病例组合中未测量差异而产生的潜在偏差。
与仅在普通医疗领域接受治疗的受益人相比，接受心理健康专科医生诊治的受益人护理疗程更长，更有可能接受精神科特定服务，且精神科和总支出更高。在老年人中，较高的成本是较长疗程和更高强度共同作用的结果；在残疾人中，主要是由于疗程更长。在专科领域接受治疗的残疾个体中，也发现了一些对护理满意度更高的证据。然而，精神科住院率差异的证据较弱。
普通医疗领域为医疗保险受益人提供的精神卫生保健似乎不能完全替代专科领域提供的护理。我们的研究表明，专科领域的治疗模式可能更受一些患者青睐；此外，早期研究结果表明获得专科护理存在地理障碍。因此，在这一弱势群体中，服务使用与临床需求的匹配可能并不恰当。表明有必要对结果进行进一步研究。
