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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 should guide angina treatment

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 body).

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 distress.

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. 1185-1190, 1995.

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