User login
Do Physicians Who Diagnose More Mental Health Disorders Generate Lower Health Care Costs?
METHODS: We used cross-sectional analyses of claims data from an independent practice association–style (IPA) managed care organization in Rochester, New York, in 1995. The sample was made up of the 457 primary care physicians in the IPA and the 243,000 adult patients assigned to their panels. We looked at total expenditures per panel member per year generated by each primary care physician and avoidable hospitalizations among their patients.
RESULTS: After adjustment for case mix, physicians who recorded a greater proportion of mental health diagnoses generated significantly lower per panel member expenditures. For physicians in the highest quartile of recording mental health diagnoses, expenditures were 9% lower than those of physicians in the lowest quartile (95% confidence interval, 5%–13%). There was a trend (P = .051) for patients of physicians in the highest quartile of recording mental health diagnoses to be at lower risk for an avoidable hospitalization than those of physicians in the lowest quartile.
CONCLUSIONS: Primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admitted for avoidable hospitalization conditions.
In the managed care system there has been increasing recognition of the role of the primary care physician in the treatment of mental health problems. More than 70% of mental health disorders are treated solely in primary care, which has been called the “de facto mental health care system.”1 More than 25% of primary care patients have a diagnosable mental health disorder, most of which are never detected or treated.2,3 These undetected and untreated disorders have an enormous impact on patient outcomes, health care utilization, and overall costs.4,5
Depression and anxiety disorders are the most common mental health problems in primary care and are diagnosed in 15% of all primary care visits.4 Patients with anxiety and depression have poor health status, comparable with that associated with serious chronic physical diseases, such as congestive heart failure and diabetes.6-8
The costs associated with untreated mental disorders in primary care are considerable. The annual health care cost for untreated patients with depression is nearly twice that for controls who do not have depression.9,10 Compared with a control group, patients with depression have higher rates of office visits, unexplained physical symptoms, and non-mental health hospitalizations.11 Patients who have high rates of medical services utilization have 4 times the prevalence of depression and anxiety disorders of control patients.12
Unrecognized and untreated mental health disorders in primary care are associated with more frequent medical visits and unnecessary medical evaluations, specialty referrals, and hospitalizations, which result in higher medical costs.4 However, a causal relationship has not been clearly established. Many have suggested that more effective detection and treatment of mental health disorders in primary care will reduce health care use and save money. Collaborative treatment of depression in primary care has been shown to be more cost-effective than routine care but did not lead to savings in overall medical costs.13-15 Effective treatment of depression is associated with lower medical inpatient and overall costs16; however, no studies have examined whether more effective diagnosis or treatment of mental health disorders by primary care physicians results in reduced medical costs.
We hypothesized that primary care physicians who have higher rates of mental health diagnoses will provide more efficient care for their patients, resulting in lower overall health costs without compromised care. To test these hypotheses, we examined the relationships between the proportion of mental health diagnoses by primary care physicians and both health care expenditures and the risk of their patients being admitted for avoidable hospitalization conditions.
Methods
Sample
We conducted our investigation in the Rochester, New York, metropolitan area in 1995, using the claims database of the largest local managed care organization (MCO). Approximately 500,000 people (more than 50% of the local population) were enrolled in the MCO. The MCO used an independent practice association model in which primary care physicians (PCPs) and specialists were not capitated. Each patient was assigned to a PCP, and more than 95% of the local PCPs participated in the independent practice association. The patient study sample included adults aged 25 years or older who were enrolled in the MCO and were assigned to a PCP (457 family physicians and internists) during 1995. To facilitate comparisons between the 2 specialties, visits to obstetrician/gynecologists and pregnancy-related visits were excluded. Exclusion criteria resulted in a sample of approximately 243,000 adult patients, of whom 210,000 used health care services during the year. Physician specialty, age, and sex were derived from a database maintained by the independent practice association.
Avoidable Hospitalizations
The ability to measure appropriateness of care and outcomes in claims data is limited. One risk of a focus on mental health disorders might be inadequate attention to biomedical problems. In turn, a consequence of this inattention might be less timely or effective care that increases the risk of avoidable hospitalization for biomedical conditions.17 We used the approach of Weisman and Epstein18 to classify whether hospitalizations were avoidable. On the basis of previous research,18-20 6 medical conditions met the criteria for avoidable hospitalizations: angina, congestive heart failure, hypertension, asthma, chronic obstructive pulmonary disease, and diabetes mellitus. Patients were classified according to whether they were admitted during the year for an avoidable hospitalization condition.
Analyses
We explored the relationships between physicians’ coding of mental health diagnoses and both their observed expenditures and the risk of their patients being admitted for an avoidable hospitalization condition using regression analyses. To avoid confounding by differences in case mix, we developed measures of expected expenditures and predicted risk of avoidable hospitalizations according to case mix. The primary independent variable of interest—the physicians’ coding of mental health diagnoses—was defined as the proportion of all diagnoses coded by the physician during the year within the mental health category of the International Classification of Diseases, 9th edition. Because the proportion of mental health diagnoses variable exhibited marked skewing and because we wanted to provide summary measures of the effect of recording more mental health diagnoses, this variable was categorized into quartiles. The derivation of the measures of observed expenditures per panel member, expected expenditures per panel member (case-mix adjustment), avoidable hospitalizations, and predicted risk of avoidable hospitalization (case-mix adjustment) are described in detail in the Appendix.* For methodologic reasons described in the Appendix, we conducted the expenditure analyses at the physician level and the avoidable hospitalization analyses at the patient level.
We used physician-level ordinary least squares regression analyses to examine the relationship between the proportion of mental health diagnoses recorded by the physician and observed log expenditures per panel member. This analysis adjusted for case-mix–predicted expenditures. We used patient-level logistic regression analyses to examine the relationship between the proportion of mental health diagnoses recorded by the patient’s physician and the dependent dichotomous variable. This analysis for the patient’s case mix predicted risk of avoidable hospitalization and the nesting of patients with a physician. A detailed description of these analyses is also included in the Appendix.
Results
The characteristics of physicians by their quartile of proportion of mental health diagnoses and their per panel member expenditures are shown in [Table 1]. In general, there were few statistically significant differences among the groups. Physicians recording a greater proportion of mental health diagnoses had greater expected expenditures per panel member (r = .14; P = .0017) and higher proportions of panel members who used health care services (r = .11; P = .017). Of the 243,150 patients in the database in 1995, 859 (0.35%) had at least one avoidable hospitalization.
After adjustment for expected per panel member expenditures, physicians in the higher quartiles of proportion of mental health diagnoses recorded had lower expenditures than physicians in the lowest quartile; expenditures were 9% lower for physicians in the highest quartile [Table 2]. These results were little changed after further adjustment for physician specialty, age, and sex (results not shown). The cost reductions were observed for total inpatient services, total outpatient services, and diagnostic services, but not for ambulatory visit services [Table 3].
After adjustment for predicted risk of avoidable hospitalization (case-mix adjustment), there was a trend (P = .051) for patients whose physicians were in the highest quartile of recorded mental health diagnoses to be less likely to be admitted for an avoidable condition. Patients of physicians in the highest quartile were at lower risk for an avoidable hospitalization than patients of physicians in the lowest quartile (adjusted odds ratio = 0.73; 95% confidence interval, 0.54 - 1.00). These results were little changed after further adjustment for physician specialty, age, and sex (results not shown).
Discussion
Our study demonstrates that primary care physicians who record higher proportions of mental health diagnoses generate lower overall health care costs. The lower costs can be attributed to reduced inpatient diagnostic testing and total outpatient costs, but not to physician visit costs. In addition, the patients of physicians with the highest proportion of recorded mental health diagnoses may be less likely to be admitted for an avoidable hospitalization.
In our study the largest reduction in health care expenditures occurred with inpatient services, where there was a 20% difference between physicians in the highest and lowest quartiles of recorded mental health diagnoses. This result is consistent with previous research showing reduced total and inpatient costs after treatment of mental health disorders.21 Katon and colleagues16 found that patients with depression who received recommended levels of antidepressant treatment had dramatically lower non–mental health-related inpatient costs. These findings suggest that the detection and treatment of mental health disorders may have its main impact on health costs by reducing hospital admissions or lengths of stay.
The reduced expenditures of the physicians with higher proportions of recorded mental health diagnoses may result from 2 pathways: less medical workup of unexplained medical symptoms and more efficient treatment of mental health disorders. These physicians may recognize when unexplained medical symptoms are the result of emotional distress or a mental health diagnosis. They may be less likely to order diagnostic tests, refer to specialists, or admit patients to the hospital. For example, the young patient with chest pain and a normal electrocardiogram may be recognized as having panic disorder and not hospitalized.
Also, the higher proportion of recorded mental health diagnoses likely results in more efficient treatment for these patients. Studies have demonstrated that the effective treatment of depression is associated with improved health status and reduced health care use and costs.21,22 Mental health diagnoses, particularly depression, are associated with poor outcomes from chronic physical disorders, and effective treatment of depression is likely to improve the medical outcome of these illnesses.
In our study, the physicians with higher proportions of recorded mental health diagnoses had lower diagnostic testing expenses, suggesting that some of their patients may have received less medical workup. The lower inpatient expenses may have resulted from avoidance of hospitalization of patients with unexplained symptoms that are attributable to a mental health disorder or to the improved health of patients whose mental health problems were treated. The costs associated with visits to a primary care physician were the same in all groups and may be the least likely to be affected by mental health diagnoses. Any reduction in outpatient medical visits for physical symptoms may be offset by visits to treat mental health problems.
Previous studies reveal little about the impact of physicians’ recording of mental health diagnoses on health care costs. A few studies have suggested that appropriate identification and treatment of somatization and mental health disorders are cost-effective and may reduce medical costs. Smith and coworkers have demonstrated that psychiatric consultation23,24 and group therapy25 for patients with somatization disorders can improve medical outcomes and substantially reduce health care costs. Two randomized controlled trials demonstrated that the treatment of depression in primary care is cost-effective, and patients who receive adequate antidepressant treatment have lower overall medical costs.13,26 A technically oriented physician practice style has been associated with higher medical costs.27
We found that physicians in the highest quartile of recorded mental health diagnoses may be less likely to have their patients admitted for an avoidable hospitalization condition, but the effect was not statistically significant. This finding suggests that the medical care of these physicians for these conditions was at least as appropriate as more biomedically focused physicians. If the physicians with higher rates of mental health diagnoses were paying inadequate attention to biomedical problems, higher rates of avoidable hospitalizations might be expected. In a related study, Bertakis and colleagues28 found that a practice style that emphasized the psychosocial aspects of care (including discussing the current emotional state of the patient) was predictive of improvement in the patient’s health status after 1 year.
It is important to note that even the physicians in the highest quartile of proportion of recorded mental health diagnoses made the diagnosis of a mental health disorder in only 9% of their patients and were probably underrecording mental health diagnoses. Epidemiologic studies suggest that 25% or more of primary care patients have a diagnosable mental health disorder.2,3 This is consistent with other studies that have shown that primary care physicians underdiagnose and undertreat mental health disorders but tend to identify and treat patients with more severe mental health disorders that are associated with significant functional impairments.29,30
Limitations
There are several limitations to our study. This is an ecologic study in which it is not possible to link the mental health diagnoses in particular patients with lower health care costs. We cannot determine whether the lower health care costs occur only in patients who received a mental health diagnosis or occur for all patients of physicians in the highest quartile. It is possible that these findings are the result of a physician trait or style, such as patient-centeredness, that is associated with both higher proportions of mental health diagnoses and lower health care costs.
It is also possible that physicians with higher proportions of recorded mental health diagnoses had more patients with more mental health problems but overall lower severity of illness. Although the analysis of health care expenditures is adjusted for case mix using the ambulatory care groups (ACG) system, this adjustment may not have adequately controlled for the severity of illness in the panels of the physicians with lower proportions of mental health diagnoses. However, the physicians with the highest proportion of recorded mental health diagnoses also had the highest expected expenditures, a measure of the illness severity of their patients. Thus, inadequate adjustment for case-mix severity should result in higher expenditures for the physicians with higher proportions of recorded mental health diagnoses. Conversely, the ACG system may have resulted in overadjustment for case mix: Physicians with a greater proportion of recorded mental health diagnoses may also have coded the other problems with greater severity, making their patients appear more ill.
The absence of data leaves open the possibility that higher medication costs generated by physicians coding more mental health diagnoses offset lower inpatient and testing costs. If these physicians prescribed more antidepressants, particularly selective serotonin reuptake inhibitors, then the costs of these drugs may partially offset their lower expenditures in other areas. Total pharmacy expenditures for antidepressants, however, accounted for less than 2% of total expenditures in 1997, a percentage that has increased since 1995. Thus, it is unlikely that this missing information could explain the differences observed. The total expenditures include inpatient and outpatient mental health costs generated by each physician.
The use of risk of avoidable hospitalizations as a measure of appropriateness of care for biomedical problems is of questionable validity. Even if valid, it is a relatively insensitive measure. It is reassuring that the proportion of recorded mental health diagnoses was associated with lower avoidable hospitalization rates. This suggests that physicians with higher proportions of recorded mental health diagnoses are not neglecting biomedical problems in their patients and may be providing better medical care. However, one study found that a patient-centered or integrated approach (which addressed the psychosocial components of care) to non–insulin-dependent diabetes was associated with improved patient satisfaction and well-being but poorer control of cardiovascular risk factors.31 Further study on the relationship between physician style and patient outcomes is needed.
Our analyses are cross-sectional, so no conclusions about causality can be made. Unmeasured confounding may also account for the findings. The results may not be generalizable beyond the managed care organization studied. However, the subjects in our analysis represented more than 50% of the patients and 95% of the primary care physicians in the metropolitan area studied. In this managed care organization, there was no financial disincentive for making mental health diagnoses (they are reimbursed at the same rates as medical diagnoses), and 50% of the cost of outpatient specialist mental health treatment was covered.
We used diagnoses coded by the physicians for insurance billing purposes. Although coded diagnoses cannot tell us what occurs during the visit, we speculate that the coding of a mental health diagnosis requires that the physician recognizes the disorder and has some type of implicit or explicit negotiation with the patient that makes recording the diagnosis acceptable. It has been shown that physicians tend to underreport mental health diagnoses because of concerns about reimbursement or stigmatizing the patient.32 The proportion of recorded mental health diagnoses can be seen as a reflection of the extent to which the physician-patient interaction legitimizes this category of diagnoses.
Conclusions
There is increasing recognition of the importance of diagnosing mental health disorders in primary care and the significance of those diagnoses on patient outcomes and medical costs. The results of our study suggest that physicians who record higher proportions of mental health diagnoses have lower health care costs. These results are consistent with the hypothesis that increased detection and treatment of mental health disorders in primary care may reduce overall health care costs. Previous studies have demonstrated that psychosocial orientation and communication style can predict a physician’s ability to detect mental health problems.33-35 Physicians can be trained to improve their communication skills and detect and manage emotional distress.36 Randomized trials have demonstrated that communication training for physicians can result in improved detection of psychological disorders and less anxiety and emotional distress in their patients.37 Our results should provide further incentive to investigate how physicians’ practice styles differ and how to improve the primary care physician’s ability to recognize and diagnose mental health disorders.
Acknowledgments
This study was supported by a grant from the Agency for Policy Health Care and Research, R01 HS09397-01.
1. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry 1978;35:685-93.
2. Schulberg HC, Burns BJ. Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions. Gen Hosp Psychiatry 1988;10:79-87.
3. Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients. Underrecognition and misdiagnosis. Arch Intern Med 1990;150:1083-8.
4. Miranda J, Hohmann AA, Attkisson CC, Larson DB. Mental Disorders in Primary Care. San Francisco, Calif: Jossey-Bass; 1994.
5. Ford DE, Kamerow DB. Screening for psychiatric and substance abuse disorders in clinical practice. J Gen Intern Med 1990;5:S37-41.
6. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;262:914-9.
7. Broadhead WE, Blazer DG, George LK, Tse CK. Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA 1990;264:2524-8.
8. Fifer SK, Mathias SD, Patrick DL, Mazonson PD, Lubeck DP, Buesching DP. Untreated anxiety among adult primary care patients in a Health Maintenance Organization. Arch Gen Psychiatry 1994;51:740-50.
9. Simon G, Ormel J, Von Korff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 1995;152:352-7.
10. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. Depression: a neglected major illness. J Clin Psychiatry 1993;54:419-24.
11. Unutzer J, Patrick DL, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study. JAMA 1997;277:1618-23.
12. Katon W, Von Korff M, Lin E, et al. Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990;12:355-62.
13. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995;273:1026-31.
14. Von Korff M, Katon W, Bush T, et al. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosom Med 1998;60:143-9.
15. Lave JR, Frank RG, Schulberg HC, Kamlet MS. Cost effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry 1998;55:645-51.
16. Revicki DA, Simon GE, Chan K, Katon W, Heiligenstein J. Depression, health-related quality of life, and medical cost outcomes of receiving recommended levels of antidepressant treatment. J Fam Pract 1998;47:446-52.
17. Pappas G, Hadden WC, Kozak LJ, Fisher GF. Potentially avoidable hospitalizations: inequalities in rates between US socioeconomic groups. Am J Pub Health 1997;87:811-6.
18. Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA 1992;268:2388-94.
19. Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA 1995;274:305-11.
20. Parchman ML, Culler S. Primary care physicians and avoidable hospitalizations. J Fam Pract 1994;39:123-8.
21. Simon GE, Katon W, Rutter C, et al. Impact of improved depression treatment in primary care on daily functioning and disability. Psychol Med 1998;28:693-701.
22. Coulehan JL, Schulberg HC, Block MR, Madonia MJ, Rodriguez E. Treating depressed primary care patients improves their physical, mental, and social functioning. Arch Intern Med 1997;157:1113-20.
23. Smith GR, Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder: a randomized controlled study. N Engl J Med 1986;314:1407-13.
24. Smith GR, Jr, Rost K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995;52:238-43.
25. Kashner TM, Rost K, Cohen B, Anderson M, Smith GR, Jr. Enhancing the health of somatization disorder patients: effectiveness of short-term group therapy. Psychosomatics 1995;36:462-70.
26. Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice: eight-month clinical outcomes. Arch Gen Psychiatry 1996;53:913-9.
27. Bertakis KD, Azari R, Callahan EJ, Helms LJ, Robbins JA. The impact of physician practice style on medical charges. J Fam Pract 1999;48:31-6.
28. Bertakis KD, Callahan EJ, Helms LJ, Azari R, Robbins JA, Miller J. Physician practice styles and patient outcomes: differences between family practice and general internal medicine. Med Care 1998;36:879-91.
29. Coyne JC, Schwenk TL, Fechner-Bates S. Nondetection of depression by primary care physicians reconsidered. Gen Hosp Psychiatry 1995;17:3-12.
30. Simon GE, Von Korff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995;4:99-105.
31. Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team. BMJ 1998;317:1202-8.
32. Rost K, Smith R, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med 1994;3:333-7.
33. Robbins JM, Kirmayer LJ, Cathebras P, Yaffe MJ, Dworkind M. Physician characteristics and the recognition of depression and anxiety in primary care. Med Care 1994;32:795-812.
34. Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734-41.
35. Goldberg DP, Jenkins L, Millar T, Faragher EB. The ability of trainee general practitioners to identify psychological distress among their patients. Psychol Med 1993;23:185-93.
36. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877-84.
37. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152:1423-33.
38. Weiner JP, Starfield BH, Steinwachs DM, Mumford LM. Development and application of a population-oriented measure of ambulatory care case-mix. Med Care 1991;29:452-72.
39. Duan N, Manning WG, Jr, Morris CN, Newhouse JP. A comparison of alternative models of demand for medical care. R-2754-HHS. Santa Monica, Calif: RAND; 1982.
40. Liang KY, Zeger SL. Regression analysis for correlated data. Annual Review of Public Health 1993;14:43-68.
METHODS: We used cross-sectional analyses of claims data from an independent practice association–style (IPA) managed care organization in Rochester, New York, in 1995. The sample was made up of the 457 primary care physicians in the IPA and the 243,000 adult patients assigned to their panels. We looked at total expenditures per panel member per year generated by each primary care physician and avoidable hospitalizations among their patients.
RESULTS: After adjustment for case mix, physicians who recorded a greater proportion of mental health diagnoses generated significantly lower per panel member expenditures. For physicians in the highest quartile of recording mental health diagnoses, expenditures were 9% lower than those of physicians in the lowest quartile (95% confidence interval, 5%–13%). There was a trend (P = .051) for patients of physicians in the highest quartile of recording mental health diagnoses to be at lower risk for an avoidable hospitalization than those of physicians in the lowest quartile.
CONCLUSIONS: Primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admitted for avoidable hospitalization conditions.
In the managed care system there has been increasing recognition of the role of the primary care physician in the treatment of mental health problems. More than 70% of mental health disorders are treated solely in primary care, which has been called the “de facto mental health care system.”1 More than 25% of primary care patients have a diagnosable mental health disorder, most of which are never detected or treated.2,3 These undetected and untreated disorders have an enormous impact on patient outcomes, health care utilization, and overall costs.4,5
Depression and anxiety disorders are the most common mental health problems in primary care and are diagnosed in 15% of all primary care visits.4 Patients with anxiety and depression have poor health status, comparable with that associated with serious chronic physical diseases, such as congestive heart failure and diabetes.6-8
The costs associated with untreated mental disorders in primary care are considerable. The annual health care cost for untreated patients with depression is nearly twice that for controls who do not have depression.9,10 Compared with a control group, patients with depression have higher rates of office visits, unexplained physical symptoms, and non-mental health hospitalizations.11 Patients who have high rates of medical services utilization have 4 times the prevalence of depression and anxiety disorders of control patients.12
Unrecognized and untreated mental health disorders in primary care are associated with more frequent medical visits and unnecessary medical evaluations, specialty referrals, and hospitalizations, which result in higher medical costs.4 However, a causal relationship has not been clearly established. Many have suggested that more effective detection and treatment of mental health disorders in primary care will reduce health care use and save money. Collaborative treatment of depression in primary care has been shown to be more cost-effective than routine care but did not lead to savings in overall medical costs.13-15 Effective treatment of depression is associated with lower medical inpatient and overall costs16; however, no studies have examined whether more effective diagnosis or treatment of mental health disorders by primary care physicians results in reduced medical costs.
We hypothesized that primary care physicians who have higher rates of mental health diagnoses will provide more efficient care for their patients, resulting in lower overall health costs without compromised care. To test these hypotheses, we examined the relationships between the proportion of mental health diagnoses by primary care physicians and both health care expenditures and the risk of their patients being admitted for avoidable hospitalization conditions.
Methods
Sample
We conducted our investigation in the Rochester, New York, metropolitan area in 1995, using the claims database of the largest local managed care organization (MCO). Approximately 500,000 people (more than 50% of the local population) were enrolled in the MCO. The MCO used an independent practice association model in which primary care physicians (PCPs) and specialists were not capitated. Each patient was assigned to a PCP, and more than 95% of the local PCPs participated in the independent practice association. The patient study sample included adults aged 25 years or older who were enrolled in the MCO and were assigned to a PCP (457 family physicians and internists) during 1995. To facilitate comparisons between the 2 specialties, visits to obstetrician/gynecologists and pregnancy-related visits were excluded. Exclusion criteria resulted in a sample of approximately 243,000 adult patients, of whom 210,000 used health care services during the year. Physician specialty, age, and sex were derived from a database maintained by the independent practice association.
Avoidable Hospitalizations
The ability to measure appropriateness of care and outcomes in claims data is limited. One risk of a focus on mental health disorders might be inadequate attention to biomedical problems. In turn, a consequence of this inattention might be less timely or effective care that increases the risk of avoidable hospitalization for biomedical conditions.17 We used the approach of Weisman and Epstein18 to classify whether hospitalizations were avoidable. On the basis of previous research,18-20 6 medical conditions met the criteria for avoidable hospitalizations: angina, congestive heart failure, hypertension, asthma, chronic obstructive pulmonary disease, and diabetes mellitus. Patients were classified according to whether they were admitted during the year for an avoidable hospitalization condition.
Analyses
We explored the relationships between physicians’ coding of mental health diagnoses and both their observed expenditures and the risk of their patients being admitted for an avoidable hospitalization condition using regression analyses. To avoid confounding by differences in case mix, we developed measures of expected expenditures and predicted risk of avoidable hospitalizations according to case mix. The primary independent variable of interest—the physicians’ coding of mental health diagnoses—was defined as the proportion of all diagnoses coded by the physician during the year within the mental health category of the International Classification of Diseases, 9th edition. Because the proportion of mental health diagnoses variable exhibited marked skewing and because we wanted to provide summary measures of the effect of recording more mental health diagnoses, this variable was categorized into quartiles. The derivation of the measures of observed expenditures per panel member, expected expenditures per panel member (case-mix adjustment), avoidable hospitalizations, and predicted risk of avoidable hospitalization (case-mix adjustment) are described in detail in the Appendix.* For methodologic reasons described in the Appendix, we conducted the expenditure analyses at the physician level and the avoidable hospitalization analyses at the patient level.
We used physician-level ordinary least squares regression analyses to examine the relationship between the proportion of mental health diagnoses recorded by the physician and observed log expenditures per panel member. This analysis adjusted for case-mix–predicted expenditures. We used patient-level logistic regression analyses to examine the relationship between the proportion of mental health diagnoses recorded by the patient’s physician and the dependent dichotomous variable. This analysis for the patient’s case mix predicted risk of avoidable hospitalization and the nesting of patients with a physician. A detailed description of these analyses is also included in the Appendix.
Results
The characteristics of physicians by their quartile of proportion of mental health diagnoses and their per panel member expenditures are shown in [Table 1]. In general, there were few statistically significant differences among the groups. Physicians recording a greater proportion of mental health diagnoses had greater expected expenditures per panel member (r = .14; P = .0017) and higher proportions of panel members who used health care services (r = .11; P = .017). Of the 243,150 patients in the database in 1995, 859 (0.35%) had at least one avoidable hospitalization.
After adjustment for expected per panel member expenditures, physicians in the higher quartiles of proportion of mental health diagnoses recorded had lower expenditures than physicians in the lowest quartile; expenditures were 9% lower for physicians in the highest quartile [Table 2]. These results were little changed after further adjustment for physician specialty, age, and sex (results not shown). The cost reductions were observed for total inpatient services, total outpatient services, and diagnostic services, but not for ambulatory visit services [Table 3].
After adjustment for predicted risk of avoidable hospitalization (case-mix adjustment), there was a trend (P = .051) for patients whose physicians were in the highest quartile of recorded mental health diagnoses to be less likely to be admitted for an avoidable condition. Patients of physicians in the highest quartile were at lower risk for an avoidable hospitalization than patients of physicians in the lowest quartile (adjusted odds ratio = 0.73; 95% confidence interval, 0.54 - 1.00). These results were little changed after further adjustment for physician specialty, age, and sex (results not shown).
Discussion
Our study demonstrates that primary care physicians who record higher proportions of mental health diagnoses generate lower overall health care costs. The lower costs can be attributed to reduced inpatient diagnostic testing and total outpatient costs, but not to physician visit costs. In addition, the patients of physicians with the highest proportion of recorded mental health diagnoses may be less likely to be admitted for an avoidable hospitalization.
In our study the largest reduction in health care expenditures occurred with inpatient services, where there was a 20% difference between physicians in the highest and lowest quartiles of recorded mental health diagnoses. This result is consistent with previous research showing reduced total and inpatient costs after treatment of mental health disorders.21 Katon and colleagues16 found that patients with depression who received recommended levels of antidepressant treatment had dramatically lower non–mental health-related inpatient costs. These findings suggest that the detection and treatment of mental health disorders may have its main impact on health costs by reducing hospital admissions or lengths of stay.
The reduced expenditures of the physicians with higher proportions of recorded mental health diagnoses may result from 2 pathways: less medical workup of unexplained medical symptoms and more efficient treatment of mental health disorders. These physicians may recognize when unexplained medical symptoms are the result of emotional distress or a mental health diagnosis. They may be less likely to order diagnostic tests, refer to specialists, or admit patients to the hospital. For example, the young patient with chest pain and a normal electrocardiogram may be recognized as having panic disorder and not hospitalized.
Also, the higher proportion of recorded mental health diagnoses likely results in more efficient treatment for these patients. Studies have demonstrated that the effective treatment of depression is associated with improved health status and reduced health care use and costs.21,22 Mental health diagnoses, particularly depression, are associated with poor outcomes from chronic physical disorders, and effective treatment of depression is likely to improve the medical outcome of these illnesses.
In our study, the physicians with higher proportions of recorded mental health diagnoses had lower diagnostic testing expenses, suggesting that some of their patients may have received less medical workup. The lower inpatient expenses may have resulted from avoidance of hospitalization of patients with unexplained symptoms that are attributable to a mental health disorder or to the improved health of patients whose mental health problems were treated. The costs associated with visits to a primary care physician were the same in all groups and may be the least likely to be affected by mental health diagnoses. Any reduction in outpatient medical visits for physical symptoms may be offset by visits to treat mental health problems.
Previous studies reveal little about the impact of physicians’ recording of mental health diagnoses on health care costs. A few studies have suggested that appropriate identification and treatment of somatization and mental health disorders are cost-effective and may reduce medical costs. Smith and coworkers have demonstrated that psychiatric consultation23,24 and group therapy25 for patients with somatization disorders can improve medical outcomes and substantially reduce health care costs. Two randomized controlled trials demonstrated that the treatment of depression in primary care is cost-effective, and patients who receive adequate antidepressant treatment have lower overall medical costs.13,26 A technically oriented physician practice style has been associated with higher medical costs.27
We found that physicians in the highest quartile of recorded mental health diagnoses may be less likely to have their patients admitted for an avoidable hospitalization condition, but the effect was not statistically significant. This finding suggests that the medical care of these physicians for these conditions was at least as appropriate as more biomedically focused physicians. If the physicians with higher rates of mental health diagnoses were paying inadequate attention to biomedical problems, higher rates of avoidable hospitalizations might be expected. In a related study, Bertakis and colleagues28 found that a practice style that emphasized the psychosocial aspects of care (including discussing the current emotional state of the patient) was predictive of improvement in the patient’s health status after 1 year.
It is important to note that even the physicians in the highest quartile of proportion of recorded mental health diagnoses made the diagnosis of a mental health disorder in only 9% of their patients and were probably underrecording mental health diagnoses. Epidemiologic studies suggest that 25% or more of primary care patients have a diagnosable mental health disorder.2,3 This is consistent with other studies that have shown that primary care physicians underdiagnose and undertreat mental health disorders but tend to identify and treat patients with more severe mental health disorders that are associated with significant functional impairments.29,30
Limitations
There are several limitations to our study. This is an ecologic study in which it is not possible to link the mental health diagnoses in particular patients with lower health care costs. We cannot determine whether the lower health care costs occur only in patients who received a mental health diagnosis or occur for all patients of physicians in the highest quartile. It is possible that these findings are the result of a physician trait or style, such as patient-centeredness, that is associated with both higher proportions of mental health diagnoses and lower health care costs.
It is also possible that physicians with higher proportions of recorded mental health diagnoses had more patients with more mental health problems but overall lower severity of illness. Although the analysis of health care expenditures is adjusted for case mix using the ambulatory care groups (ACG) system, this adjustment may not have adequately controlled for the severity of illness in the panels of the physicians with lower proportions of mental health diagnoses. However, the physicians with the highest proportion of recorded mental health diagnoses also had the highest expected expenditures, a measure of the illness severity of their patients. Thus, inadequate adjustment for case-mix severity should result in higher expenditures for the physicians with higher proportions of recorded mental health diagnoses. Conversely, the ACG system may have resulted in overadjustment for case mix: Physicians with a greater proportion of recorded mental health diagnoses may also have coded the other problems with greater severity, making their patients appear more ill.
The absence of data leaves open the possibility that higher medication costs generated by physicians coding more mental health diagnoses offset lower inpatient and testing costs. If these physicians prescribed more antidepressants, particularly selective serotonin reuptake inhibitors, then the costs of these drugs may partially offset their lower expenditures in other areas. Total pharmacy expenditures for antidepressants, however, accounted for less than 2% of total expenditures in 1997, a percentage that has increased since 1995. Thus, it is unlikely that this missing information could explain the differences observed. The total expenditures include inpatient and outpatient mental health costs generated by each physician.
The use of risk of avoidable hospitalizations as a measure of appropriateness of care for biomedical problems is of questionable validity. Even if valid, it is a relatively insensitive measure. It is reassuring that the proportion of recorded mental health diagnoses was associated with lower avoidable hospitalization rates. This suggests that physicians with higher proportions of recorded mental health diagnoses are not neglecting biomedical problems in their patients and may be providing better medical care. However, one study found that a patient-centered or integrated approach (which addressed the psychosocial components of care) to non–insulin-dependent diabetes was associated with improved patient satisfaction and well-being but poorer control of cardiovascular risk factors.31 Further study on the relationship between physician style and patient outcomes is needed.
Our analyses are cross-sectional, so no conclusions about causality can be made. Unmeasured confounding may also account for the findings. The results may not be generalizable beyond the managed care organization studied. However, the subjects in our analysis represented more than 50% of the patients and 95% of the primary care physicians in the metropolitan area studied. In this managed care organization, there was no financial disincentive for making mental health diagnoses (they are reimbursed at the same rates as medical diagnoses), and 50% of the cost of outpatient specialist mental health treatment was covered.
We used diagnoses coded by the physicians for insurance billing purposes. Although coded diagnoses cannot tell us what occurs during the visit, we speculate that the coding of a mental health diagnosis requires that the physician recognizes the disorder and has some type of implicit or explicit negotiation with the patient that makes recording the diagnosis acceptable. It has been shown that physicians tend to underreport mental health diagnoses because of concerns about reimbursement or stigmatizing the patient.32 The proportion of recorded mental health diagnoses can be seen as a reflection of the extent to which the physician-patient interaction legitimizes this category of diagnoses.
Conclusions
There is increasing recognition of the importance of diagnosing mental health disorders in primary care and the significance of those diagnoses on patient outcomes and medical costs. The results of our study suggest that physicians who record higher proportions of mental health diagnoses have lower health care costs. These results are consistent with the hypothesis that increased detection and treatment of mental health disorders in primary care may reduce overall health care costs. Previous studies have demonstrated that psychosocial orientation and communication style can predict a physician’s ability to detect mental health problems.33-35 Physicians can be trained to improve their communication skills and detect and manage emotional distress.36 Randomized trials have demonstrated that communication training for physicians can result in improved detection of psychological disorders and less anxiety and emotional distress in their patients.37 Our results should provide further incentive to investigate how physicians’ practice styles differ and how to improve the primary care physician’s ability to recognize and diagnose mental health disorders.
Acknowledgments
This study was supported by a grant from the Agency for Policy Health Care and Research, R01 HS09397-01.
METHODS: We used cross-sectional analyses of claims data from an independent practice association–style (IPA) managed care organization in Rochester, New York, in 1995. The sample was made up of the 457 primary care physicians in the IPA and the 243,000 adult patients assigned to their panels. We looked at total expenditures per panel member per year generated by each primary care physician and avoidable hospitalizations among their patients.
RESULTS: After adjustment for case mix, physicians who recorded a greater proportion of mental health diagnoses generated significantly lower per panel member expenditures. For physicians in the highest quartile of recording mental health diagnoses, expenditures were 9% lower than those of physicians in the lowest quartile (95% confidence interval, 5%–13%). There was a trend (P = .051) for patients of physicians in the highest quartile of recording mental health diagnoses to be at lower risk for an avoidable hospitalization than those of physicians in the lowest quartile.
CONCLUSIONS: Primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admitted for avoidable hospitalization conditions.
In the managed care system there has been increasing recognition of the role of the primary care physician in the treatment of mental health problems. More than 70% of mental health disorders are treated solely in primary care, which has been called the “de facto mental health care system.”1 More than 25% of primary care patients have a diagnosable mental health disorder, most of which are never detected or treated.2,3 These undetected and untreated disorders have an enormous impact on patient outcomes, health care utilization, and overall costs.4,5
Depression and anxiety disorders are the most common mental health problems in primary care and are diagnosed in 15% of all primary care visits.4 Patients with anxiety and depression have poor health status, comparable with that associated with serious chronic physical diseases, such as congestive heart failure and diabetes.6-8
The costs associated with untreated mental disorders in primary care are considerable. The annual health care cost for untreated patients with depression is nearly twice that for controls who do not have depression.9,10 Compared with a control group, patients with depression have higher rates of office visits, unexplained physical symptoms, and non-mental health hospitalizations.11 Patients who have high rates of medical services utilization have 4 times the prevalence of depression and anxiety disorders of control patients.12
Unrecognized and untreated mental health disorders in primary care are associated with more frequent medical visits and unnecessary medical evaluations, specialty referrals, and hospitalizations, which result in higher medical costs.4 However, a causal relationship has not been clearly established. Many have suggested that more effective detection and treatment of mental health disorders in primary care will reduce health care use and save money. Collaborative treatment of depression in primary care has been shown to be more cost-effective than routine care but did not lead to savings in overall medical costs.13-15 Effective treatment of depression is associated with lower medical inpatient and overall costs16; however, no studies have examined whether more effective diagnosis or treatment of mental health disorders by primary care physicians results in reduced medical costs.
We hypothesized that primary care physicians who have higher rates of mental health diagnoses will provide more efficient care for their patients, resulting in lower overall health costs without compromised care. To test these hypotheses, we examined the relationships between the proportion of mental health diagnoses by primary care physicians and both health care expenditures and the risk of their patients being admitted for avoidable hospitalization conditions.
Methods
Sample
We conducted our investigation in the Rochester, New York, metropolitan area in 1995, using the claims database of the largest local managed care organization (MCO). Approximately 500,000 people (more than 50% of the local population) were enrolled in the MCO. The MCO used an independent practice association model in which primary care physicians (PCPs) and specialists were not capitated. Each patient was assigned to a PCP, and more than 95% of the local PCPs participated in the independent practice association. The patient study sample included adults aged 25 years or older who were enrolled in the MCO and were assigned to a PCP (457 family physicians and internists) during 1995. To facilitate comparisons between the 2 specialties, visits to obstetrician/gynecologists and pregnancy-related visits were excluded. Exclusion criteria resulted in a sample of approximately 243,000 adult patients, of whom 210,000 used health care services during the year. Physician specialty, age, and sex were derived from a database maintained by the independent practice association.
Avoidable Hospitalizations
The ability to measure appropriateness of care and outcomes in claims data is limited. One risk of a focus on mental health disorders might be inadequate attention to biomedical problems. In turn, a consequence of this inattention might be less timely or effective care that increases the risk of avoidable hospitalization for biomedical conditions.17 We used the approach of Weisman and Epstein18 to classify whether hospitalizations were avoidable. On the basis of previous research,18-20 6 medical conditions met the criteria for avoidable hospitalizations: angina, congestive heart failure, hypertension, asthma, chronic obstructive pulmonary disease, and diabetes mellitus. Patients were classified according to whether they were admitted during the year for an avoidable hospitalization condition.
Analyses
We explored the relationships between physicians’ coding of mental health diagnoses and both their observed expenditures and the risk of their patients being admitted for an avoidable hospitalization condition using regression analyses. To avoid confounding by differences in case mix, we developed measures of expected expenditures and predicted risk of avoidable hospitalizations according to case mix. The primary independent variable of interest—the physicians’ coding of mental health diagnoses—was defined as the proportion of all diagnoses coded by the physician during the year within the mental health category of the International Classification of Diseases, 9th edition. Because the proportion of mental health diagnoses variable exhibited marked skewing and because we wanted to provide summary measures of the effect of recording more mental health diagnoses, this variable was categorized into quartiles. The derivation of the measures of observed expenditures per panel member, expected expenditures per panel member (case-mix adjustment), avoidable hospitalizations, and predicted risk of avoidable hospitalization (case-mix adjustment) are described in detail in the Appendix.* For methodologic reasons described in the Appendix, we conducted the expenditure analyses at the physician level and the avoidable hospitalization analyses at the patient level.
We used physician-level ordinary least squares regression analyses to examine the relationship between the proportion of mental health diagnoses recorded by the physician and observed log expenditures per panel member. This analysis adjusted for case-mix–predicted expenditures. We used patient-level logistic regression analyses to examine the relationship between the proportion of mental health diagnoses recorded by the patient’s physician and the dependent dichotomous variable. This analysis for the patient’s case mix predicted risk of avoidable hospitalization and the nesting of patients with a physician. A detailed description of these analyses is also included in the Appendix.
Results
The characteristics of physicians by their quartile of proportion of mental health diagnoses and their per panel member expenditures are shown in [Table 1]. In general, there were few statistically significant differences among the groups. Physicians recording a greater proportion of mental health diagnoses had greater expected expenditures per panel member (r = .14; P = .0017) and higher proportions of panel members who used health care services (r = .11; P = .017). Of the 243,150 patients in the database in 1995, 859 (0.35%) had at least one avoidable hospitalization.
After adjustment for expected per panel member expenditures, physicians in the higher quartiles of proportion of mental health diagnoses recorded had lower expenditures than physicians in the lowest quartile; expenditures were 9% lower for physicians in the highest quartile [Table 2]. These results were little changed after further adjustment for physician specialty, age, and sex (results not shown). The cost reductions were observed for total inpatient services, total outpatient services, and diagnostic services, but not for ambulatory visit services [Table 3].
After adjustment for predicted risk of avoidable hospitalization (case-mix adjustment), there was a trend (P = .051) for patients whose physicians were in the highest quartile of recorded mental health diagnoses to be less likely to be admitted for an avoidable condition. Patients of physicians in the highest quartile were at lower risk for an avoidable hospitalization than patients of physicians in the lowest quartile (adjusted odds ratio = 0.73; 95% confidence interval, 0.54 - 1.00). These results were little changed after further adjustment for physician specialty, age, and sex (results not shown).
Discussion
Our study demonstrates that primary care physicians who record higher proportions of mental health diagnoses generate lower overall health care costs. The lower costs can be attributed to reduced inpatient diagnostic testing and total outpatient costs, but not to physician visit costs. In addition, the patients of physicians with the highest proportion of recorded mental health diagnoses may be less likely to be admitted for an avoidable hospitalization.
In our study the largest reduction in health care expenditures occurred with inpatient services, where there was a 20% difference between physicians in the highest and lowest quartiles of recorded mental health diagnoses. This result is consistent with previous research showing reduced total and inpatient costs after treatment of mental health disorders.21 Katon and colleagues16 found that patients with depression who received recommended levels of antidepressant treatment had dramatically lower non–mental health-related inpatient costs. These findings suggest that the detection and treatment of mental health disorders may have its main impact on health costs by reducing hospital admissions or lengths of stay.
The reduced expenditures of the physicians with higher proportions of recorded mental health diagnoses may result from 2 pathways: less medical workup of unexplained medical symptoms and more efficient treatment of mental health disorders. These physicians may recognize when unexplained medical symptoms are the result of emotional distress or a mental health diagnosis. They may be less likely to order diagnostic tests, refer to specialists, or admit patients to the hospital. For example, the young patient with chest pain and a normal electrocardiogram may be recognized as having panic disorder and not hospitalized.
Also, the higher proportion of recorded mental health diagnoses likely results in more efficient treatment for these patients. Studies have demonstrated that the effective treatment of depression is associated with improved health status and reduced health care use and costs.21,22 Mental health diagnoses, particularly depression, are associated with poor outcomes from chronic physical disorders, and effective treatment of depression is likely to improve the medical outcome of these illnesses.
In our study, the physicians with higher proportions of recorded mental health diagnoses had lower diagnostic testing expenses, suggesting that some of their patients may have received less medical workup. The lower inpatient expenses may have resulted from avoidance of hospitalization of patients with unexplained symptoms that are attributable to a mental health disorder or to the improved health of patients whose mental health problems were treated. The costs associated with visits to a primary care physician were the same in all groups and may be the least likely to be affected by mental health diagnoses. Any reduction in outpatient medical visits for physical symptoms may be offset by visits to treat mental health problems.
Previous studies reveal little about the impact of physicians’ recording of mental health diagnoses on health care costs. A few studies have suggested that appropriate identification and treatment of somatization and mental health disorders are cost-effective and may reduce medical costs. Smith and coworkers have demonstrated that psychiatric consultation23,24 and group therapy25 for patients with somatization disorders can improve medical outcomes and substantially reduce health care costs. Two randomized controlled trials demonstrated that the treatment of depression in primary care is cost-effective, and patients who receive adequate antidepressant treatment have lower overall medical costs.13,26 A technically oriented physician practice style has been associated with higher medical costs.27
We found that physicians in the highest quartile of recorded mental health diagnoses may be less likely to have their patients admitted for an avoidable hospitalization condition, but the effect was not statistically significant. This finding suggests that the medical care of these physicians for these conditions was at least as appropriate as more biomedically focused physicians. If the physicians with higher rates of mental health diagnoses were paying inadequate attention to biomedical problems, higher rates of avoidable hospitalizations might be expected. In a related study, Bertakis and colleagues28 found that a practice style that emphasized the psychosocial aspects of care (including discussing the current emotional state of the patient) was predictive of improvement in the patient’s health status after 1 year.
It is important to note that even the physicians in the highest quartile of proportion of recorded mental health diagnoses made the diagnosis of a mental health disorder in only 9% of their patients and were probably underrecording mental health diagnoses. Epidemiologic studies suggest that 25% or more of primary care patients have a diagnosable mental health disorder.2,3 This is consistent with other studies that have shown that primary care physicians underdiagnose and undertreat mental health disorders but tend to identify and treat patients with more severe mental health disorders that are associated with significant functional impairments.29,30
Limitations
There are several limitations to our study. This is an ecologic study in which it is not possible to link the mental health diagnoses in particular patients with lower health care costs. We cannot determine whether the lower health care costs occur only in patients who received a mental health diagnosis or occur for all patients of physicians in the highest quartile. It is possible that these findings are the result of a physician trait or style, such as patient-centeredness, that is associated with both higher proportions of mental health diagnoses and lower health care costs.
It is also possible that physicians with higher proportions of recorded mental health diagnoses had more patients with more mental health problems but overall lower severity of illness. Although the analysis of health care expenditures is adjusted for case mix using the ambulatory care groups (ACG) system, this adjustment may not have adequately controlled for the severity of illness in the panels of the physicians with lower proportions of mental health diagnoses. However, the physicians with the highest proportion of recorded mental health diagnoses also had the highest expected expenditures, a measure of the illness severity of their patients. Thus, inadequate adjustment for case-mix severity should result in higher expenditures for the physicians with higher proportions of recorded mental health diagnoses. Conversely, the ACG system may have resulted in overadjustment for case mix: Physicians with a greater proportion of recorded mental health diagnoses may also have coded the other problems with greater severity, making their patients appear more ill.
The absence of data leaves open the possibility that higher medication costs generated by physicians coding more mental health diagnoses offset lower inpatient and testing costs. If these physicians prescribed more antidepressants, particularly selective serotonin reuptake inhibitors, then the costs of these drugs may partially offset their lower expenditures in other areas. Total pharmacy expenditures for antidepressants, however, accounted for less than 2% of total expenditures in 1997, a percentage that has increased since 1995. Thus, it is unlikely that this missing information could explain the differences observed. The total expenditures include inpatient and outpatient mental health costs generated by each physician.
The use of risk of avoidable hospitalizations as a measure of appropriateness of care for biomedical problems is of questionable validity. Even if valid, it is a relatively insensitive measure. It is reassuring that the proportion of recorded mental health diagnoses was associated with lower avoidable hospitalization rates. This suggests that physicians with higher proportions of recorded mental health diagnoses are not neglecting biomedical problems in their patients and may be providing better medical care. However, one study found that a patient-centered or integrated approach (which addressed the psychosocial components of care) to non–insulin-dependent diabetes was associated with improved patient satisfaction and well-being but poorer control of cardiovascular risk factors.31 Further study on the relationship between physician style and patient outcomes is needed.
Our analyses are cross-sectional, so no conclusions about causality can be made. Unmeasured confounding may also account for the findings. The results may not be generalizable beyond the managed care organization studied. However, the subjects in our analysis represented more than 50% of the patients and 95% of the primary care physicians in the metropolitan area studied. In this managed care organization, there was no financial disincentive for making mental health diagnoses (they are reimbursed at the same rates as medical diagnoses), and 50% of the cost of outpatient specialist mental health treatment was covered.
We used diagnoses coded by the physicians for insurance billing purposes. Although coded diagnoses cannot tell us what occurs during the visit, we speculate that the coding of a mental health diagnosis requires that the physician recognizes the disorder and has some type of implicit or explicit negotiation with the patient that makes recording the diagnosis acceptable. It has been shown that physicians tend to underreport mental health diagnoses because of concerns about reimbursement or stigmatizing the patient.32 The proportion of recorded mental health diagnoses can be seen as a reflection of the extent to which the physician-patient interaction legitimizes this category of diagnoses.
Conclusions
There is increasing recognition of the importance of diagnosing mental health disorders in primary care and the significance of those diagnoses on patient outcomes and medical costs. The results of our study suggest that physicians who record higher proportions of mental health diagnoses have lower health care costs. These results are consistent with the hypothesis that increased detection and treatment of mental health disorders in primary care may reduce overall health care costs. Previous studies have demonstrated that psychosocial orientation and communication style can predict a physician’s ability to detect mental health problems.33-35 Physicians can be trained to improve their communication skills and detect and manage emotional distress.36 Randomized trials have demonstrated that communication training for physicians can result in improved detection of psychological disorders and less anxiety and emotional distress in their patients.37 Our results should provide further incentive to investigate how physicians’ practice styles differ and how to improve the primary care physician’s ability to recognize and diagnose mental health disorders.
Acknowledgments
This study was supported by a grant from the Agency for Policy Health Care and Research, R01 HS09397-01.
1. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry 1978;35:685-93.
2. Schulberg HC, Burns BJ. Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions. Gen Hosp Psychiatry 1988;10:79-87.
3. Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients. Underrecognition and misdiagnosis. Arch Intern Med 1990;150:1083-8.
4. Miranda J, Hohmann AA, Attkisson CC, Larson DB. Mental Disorders in Primary Care. San Francisco, Calif: Jossey-Bass; 1994.
5. Ford DE, Kamerow DB. Screening for psychiatric and substance abuse disorders in clinical practice. J Gen Intern Med 1990;5:S37-41.
6. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;262:914-9.
7. Broadhead WE, Blazer DG, George LK, Tse CK. Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA 1990;264:2524-8.
8. Fifer SK, Mathias SD, Patrick DL, Mazonson PD, Lubeck DP, Buesching DP. Untreated anxiety among adult primary care patients in a Health Maintenance Organization. Arch Gen Psychiatry 1994;51:740-50.
9. Simon G, Ormel J, Von Korff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 1995;152:352-7.
10. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. Depression: a neglected major illness. J Clin Psychiatry 1993;54:419-24.
11. Unutzer J, Patrick DL, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study. JAMA 1997;277:1618-23.
12. Katon W, Von Korff M, Lin E, et al. Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990;12:355-62.
13. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995;273:1026-31.
14. Von Korff M, Katon W, Bush T, et al. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosom Med 1998;60:143-9.
15. Lave JR, Frank RG, Schulberg HC, Kamlet MS. Cost effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry 1998;55:645-51.
16. Revicki DA, Simon GE, Chan K, Katon W, Heiligenstein J. Depression, health-related quality of life, and medical cost outcomes of receiving recommended levels of antidepressant treatment. J Fam Pract 1998;47:446-52.
17. Pappas G, Hadden WC, Kozak LJ, Fisher GF. Potentially avoidable hospitalizations: inequalities in rates between US socioeconomic groups. Am J Pub Health 1997;87:811-6.
18. Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA 1992;268:2388-94.
19. Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA 1995;274:305-11.
20. Parchman ML, Culler S. Primary care physicians and avoidable hospitalizations. J Fam Pract 1994;39:123-8.
21. Simon GE, Katon W, Rutter C, et al. Impact of improved depression treatment in primary care on daily functioning and disability. Psychol Med 1998;28:693-701.
22. Coulehan JL, Schulberg HC, Block MR, Madonia MJ, Rodriguez E. Treating depressed primary care patients improves their physical, mental, and social functioning. Arch Intern Med 1997;157:1113-20.
23. Smith GR, Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder: a randomized controlled study. N Engl J Med 1986;314:1407-13.
24. Smith GR, Jr, Rost K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995;52:238-43.
25. Kashner TM, Rost K, Cohen B, Anderson M, Smith GR, Jr. Enhancing the health of somatization disorder patients: effectiveness of short-term group therapy. Psychosomatics 1995;36:462-70.
26. Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice: eight-month clinical outcomes. Arch Gen Psychiatry 1996;53:913-9.
27. Bertakis KD, Azari R, Callahan EJ, Helms LJ, Robbins JA. The impact of physician practice style on medical charges. J Fam Pract 1999;48:31-6.
28. Bertakis KD, Callahan EJ, Helms LJ, Azari R, Robbins JA, Miller J. Physician practice styles and patient outcomes: differences between family practice and general internal medicine. Med Care 1998;36:879-91.
29. Coyne JC, Schwenk TL, Fechner-Bates S. Nondetection of depression by primary care physicians reconsidered. Gen Hosp Psychiatry 1995;17:3-12.
30. Simon GE, Von Korff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995;4:99-105.
31. Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team. BMJ 1998;317:1202-8.
32. Rost K, Smith R, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med 1994;3:333-7.
33. Robbins JM, Kirmayer LJ, Cathebras P, Yaffe MJ, Dworkind M. Physician characteristics and the recognition of depression and anxiety in primary care. Med Care 1994;32:795-812.
34. Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734-41.
35. Goldberg DP, Jenkins L, Millar T, Faragher EB. The ability of trainee general practitioners to identify psychological distress among their patients. Psychol Med 1993;23:185-93.
36. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877-84.
37. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152:1423-33.
38. Weiner JP, Starfield BH, Steinwachs DM, Mumford LM. Development and application of a population-oriented measure of ambulatory care case-mix. Med Care 1991;29:452-72.
39. Duan N, Manning WG, Jr, Morris CN, Newhouse JP. A comparison of alternative models of demand for medical care. R-2754-HHS. Santa Monica, Calif: RAND; 1982.
40. Liang KY, Zeger SL. Regression analysis for correlated data. Annual Review of Public Health 1993;14:43-68.
1. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry 1978;35:685-93.
2. Schulberg HC, Burns BJ. Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions. Gen Hosp Psychiatry 1988;10:79-87.
3. Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients. Underrecognition and misdiagnosis. Arch Intern Med 1990;150:1083-8.
4. Miranda J, Hohmann AA, Attkisson CC, Larson DB. Mental Disorders in Primary Care. San Francisco, Calif: Jossey-Bass; 1994.
5. Ford DE, Kamerow DB. Screening for psychiatric and substance abuse disorders in clinical practice. J Gen Intern Med 1990;5:S37-41.
6. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;262:914-9.
7. Broadhead WE, Blazer DG, George LK, Tse CK. Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA 1990;264:2524-8.
8. Fifer SK, Mathias SD, Patrick DL, Mazonson PD, Lubeck DP, Buesching DP. Untreated anxiety among adult primary care patients in a Health Maintenance Organization. Arch Gen Psychiatry 1994;51:740-50.
9. Simon G, Ormel J, Von Korff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 1995;152:352-7.
10. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. Depression: a neglected major illness. J Clin Psychiatry 1993;54:419-24.
11. Unutzer J, Patrick DL, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study. JAMA 1997;277:1618-23.
12. Katon W, Von Korff M, Lin E, et al. Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990;12:355-62.
13. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995;273:1026-31.
14. Von Korff M, Katon W, Bush T, et al. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosom Med 1998;60:143-9.
15. Lave JR, Frank RG, Schulberg HC, Kamlet MS. Cost effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry 1998;55:645-51.
16. Revicki DA, Simon GE, Chan K, Katon W, Heiligenstein J. Depression, health-related quality of life, and medical cost outcomes of receiving recommended levels of antidepressant treatment. J Fam Pract 1998;47:446-52.
17. Pappas G, Hadden WC, Kozak LJ, Fisher GF. Potentially avoidable hospitalizations: inequalities in rates between US socioeconomic groups. Am J Pub Health 1997;87:811-6.
18. Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA 1992;268:2388-94.
19. Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA 1995;274:305-11.
20. Parchman ML, Culler S. Primary care physicians and avoidable hospitalizations. J Fam Pract 1994;39:123-8.
21. Simon GE, Katon W, Rutter C, et al. Impact of improved depression treatment in primary care on daily functioning and disability. Psychol Med 1998;28:693-701.
22. Coulehan JL, Schulberg HC, Block MR, Madonia MJ, Rodriguez E. Treating depressed primary care patients improves their physical, mental, and social functioning. Arch Intern Med 1997;157:1113-20.
23. Smith GR, Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder: a randomized controlled study. N Engl J Med 1986;314:1407-13.
24. Smith GR, Jr, Rost K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995;52:238-43.
25. Kashner TM, Rost K, Cohen B, Anderson M, Smith GR, Jr. Enhancing the health of somatization disorder patients: effectiveness of short-term group therapy. Psychosomatics 1995;36:462-70.
26. Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice: eight-month clinical outcomes. Arch Gen Psychiatry 1996;53:913-9.
27. Bertakis KD, Azari R, Callahan EJ, Helms LJ, Robbins JA. The impact of physician practice style on medical charges. J Fam Pract 1999;48:31-6.
28. Bertakis KD, Callahan EJ, Helms LJ, Azari R, Robbins JA, Miller J. Physician practice styles and patient outcomes: differences between family practice and general internal medicine. Med Care 1998;36:879-91.
29. Coyne JC, Schwenk TL, Fechner-Bates S. Nondetection of depression by primary care physicians reconsidered. Gen Hosp Psychiatry 1995;17:3-12.
30. Simon GE, Von Korff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995;4:99-105.
31. Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team. BMJ 1998;317:1202-8.
32. Rost K, Smith R, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med 1994;3:333-7.
33. Robbins JM, Kirmayer LJ, Cathebras P, Yaffe MJ, Dworkind M. Physician characteristics and the recognition of depression and anxiety in primary care. Med Care 1994;32:795-812.
34. Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734-41.
35. Goldberg DP, Jenkins L, Millar T, Faragher EB. The ability of trainee general practitioners to identify psychological distress among their patients. Psychol Med 1993;23:185-93.
36. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877-84.
37. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152:1423-33.
38. Weiner JP, Starfield BH, Steinwachs DM, Mumford LM. Development and application of a population-oriented measure of ambulatory care case-mix. Med Care 1991;29:452-72.
39. Duan N, Manning WG, Jr, Morris CN, Newhouse JP. A comparison of alternative models of demand for medical care. R-2754-HHS. Santa Monica, Calif: RAND; 1982.
40. Liang KY, Zeger SL. Regression analysis for correlated data. Annual Review of Public Health 1993;14:43-68.