To the Editor: In an article in the January 2007 issue, Zuvekas and colleagues (1) suggested that the introduction of management practices via a managed behavioral health care organization (MBHO) does not shift "treatment" costs. We wish to take issue with the rather broad conclusion of the authors that "treatment" costs are unaffected.
At best the authors' findings would support the conclusion that during the introduction of MBHO practices, use of psychotropic medications increased (6% to 10% for large employers and 5% to 9% for medium-small employers). Further, for patients who used psychotropic medications, general mental health specialty service use increased but only to the point that the percentage of patients receiving a psychotropic medication and mental health specialty treatment rose from 24% to 31% for employees of a large company and from 16% to 24% for those in medium-small companies. Little can be said of other treatment costs experienced by employees with treatment needs for mental health or substance use disorders.
A recent study showed that 80% of health care costs for patients with psychiatric illness treated in a health care environment that handled mental health and substance use disorders independent of physical health were primarily related to physical health service use and nonpsychiatric medications (2). Perhaps more importantly, a study by Rosenheck and colleagues (3) suggested that higher medical costs are associated with the introduction of MBHO business practices in an employee population. In fact, the net increase of medical and pharmacy costs in that study was in excess of cost reductions for use of mental health and substance abuse services. Although the data did not permit these authors to assign a causal relationship between the introduction of MBHO business practices and high total health care costs, the health care cost differences were robust and the association was consistent.
In addition to our suggestion that Zuvekas and colleagues' conclusions are broader than they should be, we also have questions about the accuracy of the conclusions themselves. The authors do not identify who the prescribing physicians were at the beginning and the end of the data collection period. Becauase a majority of psychotropic prescriptions are written by nonpsychiatrists (4), there is no way to confirm that psychotropic prescriptions by nonpsychiatrist physicians did not increase from baseline to the end of the study, even with the increase in general mental health service use. Psychiatrists—mental health professionals with prescription privileges—were not separated from other mental health professionals in the study, so there is no way to confirm that increased mental health treatment translates to increased psychiatrist visits and prescriptions.
We have written this letter because Zuvekas and colleagues' article gives the impression that carving out mental health and substance abuse treatment services from the rest of medical care is acceptable from a cost perspective. On the basis of the comments above, we do not think that the real costs associated with carving out these services were addressed. Perhaps more importantly, independent management of physical and behavioral health by health plans necessarily segregates the delivery of general medical services from the delivery of mental health and substance abuse treatment services (5), leading to our current situation in which 70% of patients with mental health and substance use problems get no treatment and two-thirds of those who do get treatment receive interventions with less efficacy and effectiveness because they are provided by non-mental health providers without psychiatric support in the medical setting.
Dr. Kathol is adjunct professor in the Department of Psychiatry, University of Minnesota, Minneapolis. He is also founder and president of Cartesian Solutions, Inc., a medical management consulting company in Burnsville, Minnesota. Dr. Kishi is associate professor, Department of Psychiatry, Saitama Medical University, Kawagoe City, Saitama, Japan.
Zuvekas SH, Rupp A, Norquist G: Cost shifting under managed behavioral health care. Psychiatric Services 58:100—108, 2007
Kathol RG, McAlpine D, Kishi Y, et al: General medical and pharmacy claims expenditures in users of behavioral health services. Journal of General Internal Medicine 20:160—167, 2005
Rosenheck RA, Druss B, Stolar M, et al: Effect of declining mental health service use on employees of a large corporation. Health Affairs 18(5):193—203, 1999
Fairman KA, Drevets WC, Kreisman JJ, et al: Course of antidepressant treatment, drug type, and prescriber's specialty. Psychiatric Services 49:1180—1186, 1998
Kathol R, Saravay S, Lobo A, et al: Epidemiologic trends and costs of fragmentation. Medical Clinics of North America 90: 549—572, 2006