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(2) Is length of treatment correlated with diagnostic category, original prognosis by therapist, socio-economic level of patient, discipline and orientation of therapist, or "severity of pathology"?
(3) What happens to the spouse, parents, and children of the patients who are seen in psychiatry?
(4) Are there distinguishing patterns of complaints in the three psychotherapy groups?
(5) How do blue-collar patients differ from white-collar or professional patients in number of interviews, diagnostic label, use of medication, recommendation of hospitalization, and type of complaints?
(6) What is the nature of the illness that resulted in hospitalization before the patient came to psychiatry—and after? How often was this a diagnostic work-up because the internist could not find "anything wrong" in the clinic?
The outpatient and inpatient medical utilization for the year prior to the initial interview in the Department of Psychiatry as well as for the five years following were studied for three groups of psychotherapy patients (one interview only, brief therapy with a mean of 6.2 interviews, and long-term therapy with a mean of 33.9 interviews) and a control group of matched patients demonstrating similar criteria of distress but not, in the six years under study, seen in psychotherapy. The three psychotherapy groups as well as the control (non-psychotherapy ) group were high utilizers of medical facilities, with an average utilization significantly higher than that of the Health Plan average. Results of the study indicated significant declines in medical utilization in the psychotherapy groups when compared to the control groups whose inpatient and outpatient utilization remained relatively constant. The most significant ones occurred in the second year group of the initial interview, and the one-interview-only and brief-therapy groups did not require additional psychotherapy to maintain the lower utilization level for five years. On the other hand, after two years the long-term psychotherapy group attained a level of psychiatric utilization which remained constant through the remaining three years of study.
The combined psychiatric and medical utilization of the long-term therapy group indicated that for this small group there was no over-all decline in outpatient utilization inasmuch as psychotherapy visits seemed to supplant medical visits. On the other hand, there was a significant decline in inpatient utilization, especially in the long-term therapy group from an initial utilization of several times that of the Health Plan average, to a level comparable to that of the general adult Health Plan population. This decline in hospitalization rate tended to occur within the first year after the initial interview and remained generally comparable to the Health Plan average for the five years.
1. Avnet, Helen H.: Psychiatric Insurance : Financing Short Term Ambulatory Treatment. New York, Group Health Insurance, Inc., 1962.
2. Balint, Michael : The Doctor, His Patient and the Illness. New York, International Universities Press, 1957.
3. Balint, Michael, and Balint, Enid : Psychotherapeutic Techniques in Medicine. London, Tavistock Publications Limited, 1961.
4. Collen, M. F., Rubin, L., Neyman, J., Dantzig, G. B., Baer, R. M., and Siegelaub, A. B.: Automated multiphasic screening and diagnosis. Am. J. Pub. Health 54, 1964.
5. Cummings, N. A., Kahn, B. I., and Sparkman, B.: Psychotherapy and Medical Utilization. As cited in Greenfield, Margaret : Providing for Mental Illness. Berkeley, Calif., Berkeley Institute of Governmental Studies, University of California, 1964.
6. Follette, W. T., and Cummings, N. A.: Psychiatry and Medical Utilization. An unpublished pilot project, 1962.
7. Forsham, Peter H.: Lecture before the Permanente Medical Group, San Francisco, 1959.
(From Medical Care, September-October 1970, Vol. VIII, No. Õ] EFFECT OF A SHORT-TERM OUTPATIENT PSYCHIATRIC THERAPY BENEFIT OF THE UTILIZATION OF MEDICAL SERVICES IN A PREPAID GROUP PRACTICE MEDICAL PROGRAM
(By Irving D. Goldberg, M.P.H., o Goldie Krantz, M.A., †
and Ben Z. Locke, M.S.fi) A pilot study was conducted to measure the effect of a short-term outpatient psychiatric therapy benefit on the utilization of general medical services at Group Health Association of Washington, D.C. (GHA), a prepaid group practice medical program. The study group consisted of 256 patients who were referred for such outpatient therapy and who were GHA members for a full 12-month period both before and after the psychiatric referral. Study patients experienced a marked reduction during the year after referral as compared with the prior year in the utilization of GHA nonpsychiatric physician services and laboratory or X-ray procedures. The reduction in number of patients seen was 13.6 percent for nonpsychiatric physician services, and 15.7 percent for laboratory or X-ray procedures. In terms of visits made, reduction was approximately 30 percent for each of these services. Basic findings of reduced utilization was still obtained when factors of age, race, sex, psychiatric diagnosis, and number of therapy sessions attended under benefit were taken into account. Results support findings of reduced utilization in other studies and suggest more efficient utilization of appropriate medical services as a result of short-term outpatient mental health benefit
in prepaid health plan settings. Only in the past decade have significant increases in mental health benefits been included in the rapid growth in health insurance protection through private voluntary insuring organizations. Since 1963, the National Institute of Mental Health (NIMH) has actively stimulated this development of encouraging the expansion of private voluntary health insurance coverage for mental health.  In a collaborative effort with the NIMH, the United States Civil Service Commission, which administers the Federal Employees Health Benefits program, requested insurance carriers and health plans participating in that program to incorporate new or improved mental health benefits, particularly coverage for outpatient services, into their existing benefit structures.
A total of some four million people are enrolled in community prepaid group practice health plans which are essentially comprehensive in their health coverage.  Prior to 1960, when the federal employees program went into effect, these plans in the main were without prepaid mental health benefits. However, all federal employees enrolled in these plans now have some mental health coverage, including outpatient benefits; and similar coverage is also available to other members and contractor groups in these plans.
With the adoption of mental health benefits in prepaid group practice plans, it has become possible to evaluate to some extent the effects that these benefits might have on patient utilization of nonpsychiatric medical services covered by the plans. [1, 2] Group Health Association of Washington, D.C. (GHA) cooperated with the Biometry Branch of the NIMH in conducting a small pilot study directed towards this question. This paper reports on the results of that study which is based on the first year's experience with a mental health benefit at GHA before benefits were expanded and before the total population of GHA was included.
Chief, Evaluation Studies Section, Biometry Branch, National Institute of Mental Health, Chevy Chase, Md.
† Program Analyst, Group Health Association, Inc., Washington, D.C.
†† Assistant Chief, Center for pidemiologic Studies, National Institute of Mental Health, Chevy Chase, Md.
1 The Federal Employees Health Benefits program, which became effective in 1960 under an Act of Congress, is the largest employer-sponsored contributing health insurance program in the world covering more than seven million persons, including employees, annuitants, and dependents.
SETTING AND NATURE OF SHORT-TERM MENTAL HEALTH BENEFIT
The Group Health Association of Washington, D.C. is a comprehensive prepaid group practice program whose participating population resides almost entirely in the metropolitan Washington, D.C. area and is comprised of three groups : federal government employees, D.C. transit workers, and general members. In November 1964, GHA included a limited outpatient mental health benefit in its structure of benefits for its government employee group who then comprised 66 percent of the GHA participant population of approximately 54,000. In January 1965, this benefit was extended to the general members who accounted for 18 percent of the participant population. Thus, 84 percent of the GHA population had some coverage for short-term outpatient psychiatric care at the inception of the partially prepaid benefit. Acute short-term hospital care had previously been part of the benefit structure.
At its initiation, the GHA mental health benefit offered under prepayment was essentially as follows: GHA paid up to 15 dollars for each of 10 therapy sessions in a membership-year for outpatient treatment of acute mental illness and emotional disorders subject to significant improvement through short-term outpatient therapy.' A GHA screening psychiatrist determined eligibility for referral on benefits. When the patient was referred by a GHA nonpsychiatric physician to the GHA screening psychiatrist for evaluation purposes as to eligibility for benefits, there was no charge to the patient for that visit or visits. During the study period, a patient could also self-refer to the screening psychiatrist. An evaluation of the patient's psychiatric condition was made by the screening psychiatrist and, on the basis of his diagnostic impression, he recommended appropriate psychiatric care where indicated, and he determined whether GHA coverage for benefits could be approved. If short-term therapy was authorized under the benefit, the patient was referred to psychiatrists or other mental health disciplines. If the condition was chronic, and hence not covered by the benefit, referral could still be made to another agency or psychiatrist, but no payment would be made by GHA for such care.
The basic study plan was to compare, for the case group under study, the utilization of GHA medical services before and after each patient was referred on benefits for short-term outpatient psychiatric therapy. The "before" period was the 12-month interval immediately preceding the date of referral by the screening psychiatrist. It was considered likely that virtually all of the patients undergoing therapy would have completed such care during the first three months immediately following referral. Since such therapy was apt to affect the utilization of GHA services during this period, and to allow sufficient time for completion of the therapy on benefits, the "after" period of 12 months' duration was taken to begin three months following the referral date. Thus, the records for each study patient were reviewed for a 27-month exposure period, although the three-month “psychiatric therapy interval" was not to be included in the "beforeafter" analysis of medical services utilization.
For purposes of the study, it was desirable that the study group be confined to persons who were covered by the same mental health benefit. It was, therefore, decided to limit the study group to all patients enrolled under the “high option" or "premium" plan who were referred on benefits for psychiatric therapy during the first year the benefit structure was in effect. Thus, as a by-product, the results of the study could provide a baseline for any future studies based on a revised benefit structure. (After the first year, the GHA mental health benefit substantially increased and broadened.) 
1 The limit of 10 therapy sessions was a renewable benefit each membership-year (i.e., year beginning with each anniversary date of joining the plan). Thus, if therapy was initiated towards the end of one membership-year and carried into the next, the patient could actually have as many as 19 sessions for the same referral.
Under the "low option" or "standard" plan, GHA paid up to 10 dollars (as compared with 15 dollars under “high options") per therapy session. Only about 10 percent of the GHA members are enrolled in the “low option" plan.
Since the GHA mental health benefit during the study period applied only to the federal employee and general member groups (including covered family members), they comprised the study population. The GHA medical records for these enrollees were reviewed by GHA staff to identify all patients who were referred to, and seen by, the screening psychiatrist during the period November 1, 1964 through October 31, 1965, the first full year in which the psychiatric benefit was-in effect. To protect the confidentiality of the patient, individuals were not identified by name to the study staff. Also, it should be noted that the confidential psychiatric notes are not part of the medical record and were not made accessible for this study.
A total of 726 patients (excluding GHA staff and dependents) were referred to the screening psychiatrist. Of this total, 409 patients were excluded from the study because they were judged ineligible for coverage under this benefit or because they overtly refused psychiatric care. Specifically, 161 were judged not to be in need and hence not referred for outpatient psychiatric care; 197 were referred for psychiatric care but not on benefits; referral was deferred for 45 patients; and 6 patients who would have been referred on benefits overtly refused to accept such care.
The records for the remaining 317 patients seen by the screening psychiatrist were reviewed for the 27-month period referred to earlier. From this total, 61 were eliminated from the study as follows : 57 cases were not available for the full 27-month period (35 began membership less than one year prior to the date seen by the screening psychiatrist, and 22 terminated their membership within the 15-month period following that date); for four patients the files were not available. This left 256 patients who comprised the study group. Of the final study group, 197 were enrolled in the federal employee program and 59 were general members—approximately in the same ratio to one another that these two groups comprised in the total GHA population.
As point of interest, the age distributions were examined for the 409 patients ineligible for benefits and the 61 eligibles who did not otherwise meet the study criteria. The age distribution for the former group was found to be very similar to that of the 256 study patients; however, the latter group of 61 patients had a somewhat younger age distribution than the final study group.
Aata extracted from the medical records were counts of all visits to GHA physicians for medical care, all visits for x-ray and laboratory procedures, as well as the number of visits made for psychiatric therapy under the mental health benefit. Other data abstracted for each patient, where available, were age, race, sex, and psychiatric diagnostic impression. Information on psychiatric and nonpsychiatric hospitalizations recorded in the medical record was also extracted. However, study data on hospitalizations were incomplete because such information was not generally recorded on patients who were hospitalized outside of GHA auspices. Also, during the period of study, the GHA hospitalization information was not consistently available in the progress notes which formed the primary source of data for this pilot study.
The distribution of the study population by age, sex, and race is shown in Table 1. Approximately 70 percent of the study group were from 25 to 64 years of age at time of referral on psychiatric benefits. In contrast, only 50 percent of the total GHA participant population (in the federal employee and general groups) were in this age group during the study period.  About 60 percent of the study group were female, which was slightly higher than the proportion of females in the total GHA membership. With respect to race, about 83 percent of the study group were Caucasian. Although no precise data on race are available for the total GHA membership, the proportion of Caucasians in the total membership is estimated to have been appreciably less than that in the study group. Specific psychiatric diagnosis for each patient was not uniformly recorded in the medical records. However, from information which was recorded, based on the evaluation of the screening psychiatrist or the psychiatrist providing therapy it was possible to classify the psychiatric diagnostic impression into broad categories for three fourths of the study group. Among those for whom the diagnostic impression was determined, 21 per cent were classified psychotic, 55 per cent psychoneurotic, 11 per cent with personality disorders, 11 per cent as having a transient situational personalty disorder, and 2 percent were considered to have some other psychiatric problem.
TABLE 1.-DISTRIBUTION OF STUDY GROUP BY AGE, RACE, SEX, AND PSYCHIATRIC DIAGNOSTIC IMPRESSION
Initially, the data were analyzed separately according to the specific medical department or ancillary service in which the patients were seen (i.e., internal medicine, other nonpsychiatric medical department, laboratory, x-ray). Almost 95 per cent of the visits by the study patients for physician services were made to the department of internal medicine. However, since the study findings for visits to internal medicine were similar to those for other non-psychiatric medical departments, the data for all medical departments were combined in the analysis presented here. Similarly, with respect to ancillary services, the findings on visits for laboratory procedures were essentially the same as those for X-ray visits, so the data for laboratory and x-ray services were also combined.
Study findings presented below compare separately the physician and ancillary (laboratory or x-ray) services received by the study group during the 12-month periods before and after referral on psychiatric benefits, by age, race, sex, diagnosis, and number of psychiatric therapy sessions attended on benefits. It was not possible to conduct a "before-after” analysis with respect to utilization of psychiatric services. Although some psychiatric counseling was provided on a feefor-service basis prior to the initiation of the mental health benefit, there was no psychiatry department as such at GHA at that time and, therefore, no comparable or meaningful basis for comparison. Thus, the “before-after" analysis was limited to utilization of nonpsychiatric medical services.
Table 2 shows the number of study patients who received care from the various GHA departments, except psychiatry, and the number of visits made to these departments during the “ before" and "after" periods. Also shown is the per cent decrease from the "before" to the "after" period with respect to number of patients seen and number of visits made. Each visit for laboratory or X-ray services was counted only once regardless of the number of procedures performed at each visit.