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Dr. Davis. Yes. I know the medicaid and medicare reimbursement schedule, there is some pressure, almost, to treat a patient in a way that might be more expensive, since there is such a limited benefit available for outpatient. It might force the physician to hospitalize the person, where he possibly could be treated in a day patient or outpatient setting.

Senator TALMADGE. Would you submit data to the committee staff to support your argument that we can actually save money? The reluctance of the Committee on Finance and the Ways and Means Committee to expand the coverage for psychiatric care, has been in large part based on cost and no one to date has been able to submit any evidence to what the cost might be, $100 million, $5 million-so if you can submit some reasonable argument that it would save money by including some of what you have recommended, we would certainly like to have evidence of that.

Thus far, no one who has ever appeared before one of our committees has had the slightest idea of what it would cost if we would write a check that said "unlimited psychiatric treatment.'

Dr. Davis. I understand your concern.

This is the reason we are recommending the amendment to include a demonstration project which would be funded by the Federal Government, and I think it would have a great deal of credibility. These other studies are pretty good and pretty indicative. I will send them along to you.

Senator TALMADGE. Thank you.
Senator Dole?

Senator DOLE. I am just curious about the number of psychiatric patients who are hospitalized in general hospitals as opposed to psychiatric hospitals.

Dr. Davis. You are asking about the number?
Senator DOLE. Yes. If you do not have it, furnish it for the record.

[The figures requested by Senator Dole and information previously requested by Senator Talmadge follow. Oral testimony continues on P. 132.]

There are 28,706 psychiatric beds in non-Federal general hospitals, and 16,091 beds in private psychiatric hospitals, out of a grand total of 332,127 psychiatric beds in all types of facilities in the United States. The preponderant number of psychiatric beds (222,202) are in State and county mental hospitals. Other settings include VA hospitals, CMHC's, residential treatment centers, etc.

The utilization of beds in all of these settings ranges from approximately 63 percent to 89 percent.

Source: Hospitals Statistics, 1976 edition, American Hospital Association ; from the 1975 annual survey.

BENEFITS OF MENTAL HEALTII CARE FOR HEALTH SERVICE UTILIZATION I would like to bring to your attention four studies which directly address the issue of henefits of mental health care. These studies show substantial savings in the cost of non-mental health care within Health Maintenance Organizations and health insurance plans that provide mental health benefits.

The first study took place in Group Health Association of Washington. This

1 Goldberg. Irving D. et al. "Effect of a Short-Term Outpatient Psychiatric Therapy Benefit on the Utilization of Medical Services in a Prepaid Group Practice Medical Progra'n.

Medical Care 8: 419-428 (September-October 1970). Clerk's Note.-Reprinted in this hearing at page 423.

study indicated that patients treated by mental health providers reduced their non-psychiatric physician usage within the HMO by 30.7 percent in the year after referral for mental health care compared to the preceding year. Use of laboratory and x-ray services declined by 29.8 percent. These cost savings were compared to the direct costs of providing care and it turns out that GHA has actually saved money by providing mental health services.

The second study took place in a Kaiser Plan in California. This study took a look, over a long time period, at the utilization experience of a group of mental health users and a comparison group. The conclusion of this study was that the net cost of psychiatric care in the year of therapy was $22 or about two cents per enrollee per month (approximately 1 percent utilization). The return on this cost is a savings in subsequent years of $200 to $250 per case or about 20 cents per enrollee per month.

Third study: The West German Psychoanalytic Studies. A number of studies * * took place about 20 years ago in the Federal Republic of Germany which are of great significance today in U.S.A. discussions of psychiatric coverage under National Health Insurance. The most significant studies were done by Annemarie Duehrssen, M.D. and colleagues of the Central Institute of Psychogenic Illness of the Berlin General Health Insurance office. She and her colleagues did a most extensive followup of patients after analytic psychotherapy or psychoanalysis by developing an evaluation system at the onset and the end of treatment and then followed up on nearly a thousand patients after five years.

The criteria used for evaluating patients in this particular study included (1) a precise description of the symptoms of illness as well as duration ; (2) utilization of health care especially in-hospital care; (3) the work capacity of the individuals; and (4) self-evaluation by the patients themselves of their own treatment.

Of the 1,000 4 study patients who underwent individual analytic psychotherapy or psychoanalysis the average number of hours of treatment were 100, 13 percent ended treatment prematurely, 12 percent continued privately after their limits of 200 treatments ran out and 10 percent desired further treatment after 200 visits but could not afford further treatment. One hundred one of the study patients could not be found at five-year followup, 13 had died and of the ensuing 890 reachable patients 845 were evaluated, certainly an extremely high response rate. Only 45 refused followup. Six hundred forty-seven were followed up in five years by direct interviews, 104 returned detailed questionnaires and 94 had home visits by a social worker.

In terms of outcome 13 percent of the patients were felt to have had at least one relapse during the five-year followup period. The most interesting statistic was that of the 845 followed up patients the hospital rate was .78 hospital days per year which compared to the pretreatment average of 5.3 days per year and a general average for the insured population of 2.5 hosiptal days per year. This is hospital days for any illness not just mental illness. Prognostic measures, built in at the onset of treatment, also had a high degree of validity and reliability : that is those with favorable prognosis had excellent outcome measures at the termination of treatment which held true a five-year follow-up. Those with unfavorable prognosis may have had an excellent or good evaluation after termination of treatment but that seemed to disappear at five-year followup. Therefore, the prognosis variables seem much more reliable at five-year followup than at termination.

The explanation for this was that it was much more observer biased at the termination of evaluation. The observer problem, I think, was inadequately addressed in these studies. It looked like there were at least three examiners, an initial examiner who determined the prognosis, a treater who did the followup at termination and a third and different five-year followup doctor. There was also a very high degree of patient satisfaction, 81 percent feeling strongly at five-year followup that they had been helped by the treatment.

Although there may be some methodological problems with this particular study, it is clear that followups had been conducted on a large number of patients with a sufficiently long interval between treatment and followup and

" Follette, William and Cummings. Nicholas A. "Psychiatric Services and Medical Uti. lization in a Prepaid Health Plan Setting." Medical Care 5 : 25–35 (January-February 1967.)

Reprinted in this hearing at page 415.

3 Diehrssen, Annemarie: Katamnestische Ergebnisse bei 1004 Patienten nach a nalytischer Psychotherapie. Zschr. Psycho-som. Med VIII, 2/62. Verlag Fuer Medizinische Psychologie (Goettingen).

Duehrssen, Anne marie : Die Beurteilung des Behandlungserfolges in der Psychotherapie. Zdchr. Psycho-som. Med III, 3/57. Verlag Fuer Medizinische Psychologie (Gottingen).

it was this kind of research which helped both preserve and extend the National Health Insurance benefit for the mentally ill in West Germany and led to a more efficient and effective prior authorization and peer review system throughout that country.

The fourth study is a more recent study by the Research Department of Blue Cross and Western Pennsylvania which assessed the medical/surgical utilization of a group of subscribers (N:169) who used a psychotherapy outpatient benefit in community mental health centers with a comparison group of subscribers. The findings showed that medical/surgical utilization was reduced significantly for the group who used the psychiatric benefit. The monthly cost per patient for medical services dropped by $9.41, from $16.47 to $7.06. This was well below the average per capita cost for the control group. Both medical/ surgical inpatient days per month and outpatient visits per month were down by more than 54 percent. Further, this phenomenon or reduced medical/surgical utilization with exposure to outpatient psychotherapy was found to be independent of age, sex, or employment level.

The above four studies suggest that significant benefits accrue to an insurance or prepaid system when mental health benefits are available and accessible. Any discussion about coverage for mental health under national health insurance must take these findings into account.

STEVEN S. SHARFSTEIN, M.D.

[From Medical Care, January-February 1967, Vol. V, No. 1]

PSYCHIATRIO SERVICES AND MEDICAL UTILIZATION IN A

PREPAID HEALTH PLAN SETTING

(By William Follette, M.D.,* and Nicholas A. Cumming, Ph.D.**) In two previous studies [5, 6] the psychiatric practitioner's contention that emotionally disturbed patients do not seek organic treatment for their complaints following the intervention of psychotherapy have been investigated. Although it has long been recognized that a large number of the physical complaints seen by the physician are emotionally, rather than organically, determined, the more precise relationship between problems in living and their possible expression through apparent physical symptomatology has been difficult to test experimentally. As noted in the previous study, the GHI Project (1) demonstrated that users of psychiatric services were also significantly frequent users of medical services, but the Project was not able to answer the question of whether there is a reduction in the use of medical services following psychotherapy.

Because the facilities and structure of the Kaiser Foundation Health Plan accord an experimental milieu not available to Avnet, the original pilot project in San Francisco was able to demonstrate a significant reduction in medical utilization between the year prior to psychotherapy, and the two years following its intervention. Certain methodologic problems inherent to the pilot study indicated caution and the need for refinement and replication to avoid arriving at premature conclusions. The lack of a control group of what might be termed psychologically-disturbed high-utilizers who did not receive psychotherapy was a serious omission in the first experiment. † Furthermore, an error in the tabulation of in

5 Jameson, John, Shuman, Larry J., and Young, Wanda W. "The effects of Outpatient L'sychiatric Utilization on the Costs of Providing Third-Party Coverage. Res. Series 18. December. 1976.

*Chief Psychiatrist, Kaiser Foundation Hospital and the Permanente Medical Group, San Francisco, Calif.

**Chief Psychologist, Kaiser Foundation Hospital and the Permanente Medical Group, San Francisco, Calif.

Presented at one of the Contributed Papers Sessions sponsored by the Medical Care Section at the 94th Annual Meeting of the American Public Health Association, San Francisco, Calif., Oct. 31-Nov. 4, 1968.

This study was primarily financed by Grant PH 108-64-100 (P). U.S. Public Health Service. The authors gratefully acknowledge the assistance and cooperation of Mr. Royal Crystal, Deputy Chief. Health Economics Branch. Secondary financial support for this study was through Grant No. 131-7241. Kaiser Foundation Research Institute.

This paper is a report of the first of two investigations seeking to develop and test methods of assessing the effect of psychiatric services on medical utilization in a comprehensive medical program. Part II deals with prospective, rather than respective, methodology, and will be reported later.

† The authors acknowledge their debt to Dr. M. F. Collen for this and other suggestions, and to Mr. Arthur Weissman. Medical Economist, Kaiser Foundation Medical care entities, for his expert consultation.

patient utilization was discovered after the experiment had been concluded. tt In addition, the question was raised whether the patients studied might, subsquent to the two years following psychotherapy, revert to previous patterns of somatization or, as a new pattern, merely substitute protracted and costly psychotherapy for previous medical treatment.

THE PROBLEM

This study investigated the question of whether there is a change in patients' utilization of outpatient and inpatient medical facilities after psychotherapy, comparing the patients studied to a matched group who did not receive psychotherapy.

Psychotherapy was defined as any contact with the Department of Psychiatry, even if the patient was seen for an initial interview only. The year prior to the initial contact was compared with the five subsequent years in both groups.

The problem can be stated simply : Is the provision of psychiatric services associated with a reduction of medical services utilization (defined as visits to other medical clinics, outpatient laboratory and x-ray procedures, and days of hospitalization)?

METHODOLOGY The setting.-The Kaiser Foundation Health Plan in the Northern California Region is a group-practice prepayment plan offering comprehensive hospital and professional services on a direct service basis. Professional services are provided by the Permanente Medical Group—a partnership of physicians. The Medical Group has a contract to provide comprehensive medical care to the subscribers, of whom there were more than a half million at the time of this study. The composition of the Health Plan subscribers is diverse, encompassing most socioeconomic groups. The Permanente Medical Group comprises all major medical specialties; referral from one specialty clinic to another is facilitated by the organizational features of group practice, geographical proximity and use of common medical records. During the years of this study (1950–1964), psychiatry was essentially not covered by the Northern California Health Plan on a prepaid basis, but in some areas of the Northern California region psychiatric services were available to Health Plan Subscribers at reduced rates. During the six years of the study, the psychiatric clinic staff in San Francisco consisted of psychiatrists, clinical psychologists, psychiatric social workers, resident psychiatrists at the third- or fourth-year level, and psychology interns, all full-time. The clinic operates primarily as an out-patient service for adults (age eighteen or older), for the evaluation and treatment of emotional disorders, but it also provides consultation for non-psychiatric physicians and consultation in the general hospital and the emergency room. There is no formal "intake” procedure, the first visit with any staff member being considered potentially therapeutic as well as evaluative and dispositional. Regardless of professional discipline, the person who sees the patient initially becomes that patient's therapist unless there is a reason for transfer to some other staff member, and he continues to see the patient for the duration of the therapy. An attempt is made to schedule the first interview as soon as possible after the patient calls for an appointment. There is also a "drop-in" or non-appointment service for emergencies so that patients in urgent need of psychiatric help usually can be seen immediately or at least within an hour or two of arrival at the clinic.

One of the unique aspects of this kind of associated health plan and medical group is that it tends to put a premium on health rather than on illness, i.e., it makes preventive medicine economically rewarding, thereby stimulating a constant search for the most effective and specific methods of treatment. The question of how psychiatry fits into comprehensive prepaid medical care is largely unexplored; there are not many settings in which it can he answered. Another feature of group practice in this setting is that all medical records for each patient are retained within the organization.

Subjects.--The experimental subjects for this investigation were selected systematically by including every fifth psychiatric patient whose initial interview took place between January 1 and December 31, 1960. Of the 152 patients thus selected, 80 were seen for one interview only, 41 were seen for two to eight

++ At that time days of hospitalization per patient and hy vear were tabulated from each patient's outpatient medical records. Subsenuent investigation has revealed that only about a third of the outpatient charts reviewed contained summaries of hospital admissions, and that tabulation of inpatient utilization must be made directly through the separatelykept inpatient records.

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interviews (mean of 6.2) and were defined as "brief therapy," and 31 were seen for nine or more interviews (mean of 33.9) and were defined as “long-term therapy;"

Thus, each experimental patient was matched with a control patient in the criteria above, but without reference to any other variable. Both samples ranged in age from 24 to 62, with a mean of 38.1. Of these, 52 percent were women and 63 percent were blue-collar workers or their dependents. The satisfaction of so many criteria in choosing a matched control group proved to be a tedious and time-consuming procedure.

Review of the medical records of the psychiatric sample disclosed consistent and conceptually useful notations in the year prior to the patients' coming to psychotherapy, which could be considered as criteria of psychological distress. These consisted of recordings, made by the physicians on the dates of the patients' visits, which were indicative of those patients' emotional distress, whether or not the physicians recognized this when they made the notations. These (38) criteria were assigned weights from one to three in accordance with the frequency of their appearance in medical records and in accordance with clinical experience about the significance of the criteria when encountered in psychotherapeutic practice. The criteria, with weights assigned, are presented in Table 1. In com paring the charts of the psychiatric patients with those of Health Plan patients randomly drawn, it was determined that although some criteria were occasionally present in the medical records of the latter, a weighted score of three within one year clearly differentiated the psychiatric from the non-psychiatric groups. Accordingly, therefore, in matching the control (non-psychotherapy ) group to the experimental (psychotherapy) group, the patients selected had records which indicated scores of three or more points for the year 1959. The mean weights of the three experimental groups and the control group in terms of the 38 criteria of psychological distress are presented in Table 2: note that there was no significant difference between this dimension of the two groups in 1959.

TABLE 1 -CRITERIA OF PSYCHOLOGICAL DIS

RESS WITH ASSIGNED WEIGHTS

1 point

2 points

3 points

1. Tranquilizer or sedative requested. 23. Fear of cancer, brain tumor, vene- 34. Unsubstantiated complaint there is

real disease, heart disease, leu- something wrong with genitals. 2. Doctor's statement patient is tense, kemia, diabetes, etc.

35. Psychiatric referral made or rechronicaliy tired, was reassured, 24. Health Questionnaire: yes on 3 or quested. etc.

more psychological questions.! 36. Suicidal attempt, threat, or preoc3. Patient's statement as in No. 2. 25. 2 or more accidents (bone frac- cupation. 4. Lumps in throat.

tures, etc.) within 1 yr. Patient 37. Fear of homosexuals or of homo5. Health questionnaire: yes on 1 or 2 may be alcoholic.

sexuality. psychological questions. 26. Alcoholism or its complications: 38. Nonorganic delusions and/or haliu6. Alopecia areata.

delirium tremens, peripheral cinations; paranoid ideation; 7. Vague, unsubstantiated pain.

neuropathy, cirrhosis.

psychotic thinking or psychotic 8. Tranquilizer or sedative given. 27. Spouse is angry at doctor and de- behavior. 9. Vitamin B12 shots (except for mands different treatment or pernicious anemia).

patient. 10. Negative EEG.

28. Seen by hypnotist or seeks referral 11. Migraine or psychogenic headache. to hypnotist. 12. More than 4 upper respiratory in. 29. Requests surgery, which is refused. fections per year.

30. Vasectomy: requested or per13. Menstrual or premenstrual ten- formed. sion; menopausal sx.

31. Hyperventilation syndrome. 14. Consults doctor about difficulty in 32. Repetitive movements noted by docchild rearing.

tor: tics, grimaces, manne isms, 15. Chronic allergic state.

torticollis, hysterical seizures. 16. Compulsive eating (or overeating). 33. Weight-lifting and/or health fad17. Chronic gastrointestinal upset; dism.

aereophagia. 18. Chronic skin disease. 19. Anal pruritus. 20. Excessive scratching. 21. Use of emergency room: 2 or more

per year. 22. Brings written list of symptoms or

complaints to doctor.

1 Refers to the last 4 questions (relating to emotional distress) on a Modified Cornell Medical Index-a general medical questionaire given to patients undergoing the multiphasic health check in the years concerned (1959-62).

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