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Switching health insurance plans may disrupt
care for depressed patients
Depressed patients tend to decrease their mental health visits
while switching from one type of health insurance plan to
another, and they do not increase their visits to "catch up" once
in the new plan. It doesn't matter whether they are switching to
or from fee-for-service or prepaid health plans, according to a
recently published study that was supported in part by the Agency
for Health Care Policy and Research (HS06802). This finding
should allay concern among insurers and prepaid health plans that
patients switching from fee-for-service plans defer use until
they are enrolled in prepaid plans with broader services and
lower out-of-pocket expenses. It also underscores the disruption
in care for depressed patients who switch plans.
Such disruption could reduce use of appropriate treatment, such
as maintenance therapy for recurrent depression. Thus, prepaid
plans should consider facilitating access to care for new
enrollees who have switched coverage and have a documented
history of treatment for recent depression, recommends Kenneth B.
Wells, M.D., of RAND Corporation and the University of
California, Los Angeles, the study's principal investigator.
Roland Sturm, Ph.D., lead author of the article, and his
colleagues used data from the Medical Outcomes Study of adult
outpatients enrolled in prepaid and fee-for-service plans in
three urban areas. They examined use of services by depressed
adults both before and after switching plans, controlling for
initial physical and psychological sickness.
The researchers found that the average number of mental health
visits was 35-40 percent lower in the prepaid system, especially
among patients of psychiatrists. Given their health status and
sociodemographic characteristics, patients who switched from
fee-for-service to prepaid plans had a lower-than-expected use of
services while they were enrolled in the fee-for-service sector.
The pattern is opposite for patients leaving prepaid plans, who
were among the highest users of health services before switching.
Patients switching out of prepaid plans may have preferred higher
levels of care than those who stayed in prepaid plans. Such
patients may have desired more services than prepaid systems
considered necessary and were willing to supply. Nevertheless,
most differences in use between those who switched and those who
stayed disappeared by the end of the 2-year study.
See "Mental health care utilization in prepaid and
fee-for-service plans among depressed patients in the medical
outcomes study," by Dr. Sturm, Catherine A. Jackson, Ph.D., Lisa
S. Meredith, Ph.D., and others, in HSR: Health Services
Research 30(2), pp. 319-340, 1995.
Patient preferences and symptom severity
Current clinical practice guidelines for managing chronic, stable
angina that ignore patient treatment preferences may lead to
inappropriate treatment, according to the Ischemic Heart Disease
Patient Outcomes Research Team (PORT), which is supported by the
Agency for Health Care Policy and Research (HS06503). Angina
occurs when the heart muscle wall becomes temporarily short of
oxygen during exertion or excitement, causing chest pain.
Guidelines for treating angina, such as those formulated by the
American College of Cardiology and the American Heart Association
for use of coronary artery bypass graft (CABG) surgery, base
treatment decisions solely on physiologic factors (for example,
the degree of stenosis or constriction of blood vessels and the
ability of the heart to pump blood to other parts of the
Such guidelines do not incorporate how much the patient is
bothered by angina symptoms such as chest pain, nausea, breathing
difficulty, and dizziness. Yet patients with similar functional
limitations vary considerably in how well they tolerate their
symptoms, according to the PORT researchers. For many patients
with angina, coronary artery bypass surgery offers no survival
benefit and is performed solely for symptom relief. Therefore,
how patients feel about their symptoms, combined with the risk of
postoperative mortality (which averages about 4 percent), should
guide the choice of treatment for symptom relief. The guidelines
should facilitate shared decisionmaking between the patient and
physician, suggests PORT principal investigator Elizabeth R.
DeLong, Ph.D., of Duke University Medical Center.
PORT investigators studied 220 patients with chronic stable
angina. They measured each patient's functional status and
quantified patient preferences for a specific health state using
various methods such as time trade-off (how many years of
remaining life the person would be willing to give up to be free
from symptoms) and standard gamble (what chance of death he or
she would be willing to take to be free from symptoms).
Patients with more severe angina were willing to trade-off more
years of life for fewer, but symptom-free, total life years.
However, not all patients with the same level of severity made
the same trade-offs between longer survival and symptom-free
life. This indicates that different people experiencing the same
level of clinical severity react with different levels of
See "Variation in patient utilities for outcomes of the
management of chronic stable angina: Implications for clinical
practice guidelines," by Robert F. Nease, Jr., Ph.D., Terry
Kneeland, M.P.H., Gerald T. O'Connor, Ph.D., Sc.D., and others,
in the Journal of the American Medical Association 273(15), pp.
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