Psychiatric Emergency Service Use After Implementation of Managed Care in a Public Mental Health System

OBJECTIVE: This study examined whether implementation of managed care in a public mental health system affected return visits to psychiatric emergency services within 180 days of an index visit. METHODS: Data were taken from an administrative database of 75,815 patient visits made to a hospital-based psychiatric emergency service for mental health care between January 1, 1995, and December 31, 2002. Rates of return visits for patients whose index visit occurred at least 26 weeks before a system of managed care was implemented in 1999 were compared with rates for patients whose index visit occurred after the implementation but at least 26 weeks before the data collection period ended. Declining-effects modeling was used to adjust for patients' gender, ethnicity, age, and admission status. RESULTS: A total of 37,371 patients met study criteria for inclusion: 21,135 before managed care was implemented and 16,236 after managed care was implemented. In the pre-managed care group, 3,687 patients (17 percent) made a repeat visit within 26 weeks of their index visit; 2,369 patients (15 percent) in the post-managed care group made such a repeat visit. For any given index visit to the psychiatric emergency department, patients who presented for treatment after managed care were only 90 percent as likely as patients who presented before managed care to have a return visit within the first five weeks after the index visit. However, there was essentially no difference between groups in the likelihood of a return visit by week 26 after the index visit, suggesting that managed care delayed, but did not eliminate, return visits. In addition, the number of police-accompanied index visits continued to rise after managed care was implemented (from 32.0 to 52.6 percent of all index visits), suggesting that increasing numbers of patients with mental illness in need of treatment were coming to the attention of law enforcement officials after managed care was implemented. CONCLUSIONS: Managed care strategies are often used to reduce reliance on emergency services. In this study, managed care delayed, rather than prevented, return visits to the psychiatric emergency service.