BACKGROUND: Underrecognition and undertreatment of mental health disorders in primary care have been associated with poor health outcomes and increased health care costs, but little is known about the impact of the diagnoses of mental health disorders on health care expenditures or outcomes. Our goal was to examine the relationships between the proportion of mental health diagnoses by primary care physicians and both health care expenditures and the risk of avoidable hospitalizations.
METHODS: We used cross-sectional analyses of claims data from an independent practice association–style (IPA) managed care organization in Rochester, New York, in 1995. The sample was made up of the 457 primary care physicians in the IPA and the 243,000 adult patients assigned to their panels. We looked at total expenditures per panel member per year generated by each primary care physician and avoidable hospitalizations among their patients.
RESULTS: After adjustment for case mix, physicians who recorded a greater proportion of mental health diagnoses generated significantly lower per panel member expenditures. For physicians in the highest quartile of recording mental health diagnoses, expenditures were 9% lower than those of physicians in the lowest quartile (95% confidence interval, 5%–13%). There was a trend (P = .051) for patients of physicians in the highest quartile of recording mental health diagnoses to be at lower risk for an avoidable hospitalization than those of physicians in the lowest quartile.
CONCLUSIONS: Primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admitted for avoidable hospitalization conditions.
In the managed care system there has been increasing recognition of the role of the primary care physician in the treatment of mental health problems. More than 70% of mental health disorders are treated solely in primary care, which has been called the “de facto mental health care system.”1 More than 25% of primary care patients have a diagnosable mental health disorder, most of which are never detected or treated.2,3 These undetected and untreated disorders have an enormous impact on patient outcomes, health care utilization, and overall costs.4,5
Depression and anxiety disorders are the most common mental health problems in primary care and are diagnosed in 15% of all primary care visits.4 Patients with anxiety and depression have poor health status, comparable with that associated with serious chronic physical diseases, such as congestive heart failure and diabetes.6-8
The costs associated with untreated mental disorders in primary care are considerable. The annual health care cost for untreated patients with depression is nearly twice that for controls who do not have depression.9,10 Compared with a control group, patients with depression have higher rates of office visits, unexplained physical symptoms, and non-mental health hospitalizations.11 Patients who have high rates of medical services utilization have 4 times the prevalence of depression and anxiety disorders of control patients.12
Unrecognized and untreated mental health disorders in primary care are associated with more frequent medical visits and unnecessary medical evaluations, specialty referrals, and hospitalizations, which result in higher medical costs.4 However, a causal relationship has not been clearly established. Many have suggested that more effective detection and treatment of mental health disorders in primary care will reduce health care use and save money. Collaborative treatment of depression in primary care has been shown to be more cost-effective than routine care but did not lead to savings in overall medical costs.13-15 Effective treatment of depression is associated with lower medical inpatient and overall costs16; however, no studies have examined whether more effective diagnosis or treatment of mental health disorders by primary care physicians results in reduced medical costs.
We hypothesized that primary care physicians who have higher rates of mental health diagnoses will provide more efficient care for their patients, resulting in lower overall health costs without compromised care. To test these hypotheses, we examined the relationships between the proportion of mental health diagnoses by primary care physicians and both health care expenditures and the risk of their patients being admitted for avoidable hospitalization conditions.
Methods
Sample
We conducted our investigation in the Rochester, New York, metropolitan area in 1995, using the claims database of the largest local managed care organization (MCO). Approximately 500,000 people (more than 50% of the local population) were enrolled in the MCO. The MCO used an independent practice association model in which primary care physicians (PCPs) and specialists were not capitated. Each patient was assigned to a PCP, and more than 95% of the local PCPs participated in the independent practice association. The patient study sample included adults aged 25 years or older who were enrolled in the MCO and were assigned to a PCP (457 family physicians and internists) during 1995. To facilitate comparisons between the 2 specialties, visits to obstetrician/gynecologists and pregnancy-related visits were excluded. Exclusion criteria resulted in a sample of approximately 243,000 adult patients, of whom 210,000 used health care services during the year. Physician specialty, age, and sex were derived from a database maintained by the independent practice association.