Trends in the professional mix and cost of outpatient mental health care.

BACKGROUND

In recent years, lower cost non-physician providers have been increasingly used to deliver outpatient mental health services.

METHODS

We compared 1997 and 2004 data on outpatient services provided by the Veterans Health Administration to examine trends in outpatient provider mix and to evaluate the association of outpatient provider mix with average per capita outpatient mental health costs.

RESULTS

We found a small decline in the proportion of outpatient mental health services provided by psychiatrists and an increase in the proportion of such services provided by nurses. However, greater use of non-physician providers, at the facility level, was associated with greater, rather than lower per capita outpatient costs and there was no significant change over time.

CONCLUSION

While an increasing proportion of outpatient mental health visits were with non-psychiatrists, there was not an associated decline in per capita mental health costs. Increasing VA workloads over the past decade have forced increases in psychiatrist panel size, substantially increasing physician efficiency. Additional non-physician staff have supported the development of psychosocial rehabilitation and crisis intervention capacities needed to cope with a 63% decline in inpatient beds and thus have most likely been complements of, rather than substitutes for, psychiatrists.