The managed care revolution of the past two decades has largely transformed health care delivery by shifting the majority of U.S. workers from a fee-for-service system to HMOs and preferred provider organizations (PPOs). In fact, the percentage of health plan participants covered by managed care in HMOs or PPOs increased from 48% in 1992 to the current level of 87% (Employee Benefit Research Institute, 1999).
While many clinicians and patients recognize the potential social value that could be associated with a thoughtful allocation of limited health care resources, they also experience frustration and anger as a result of managed care's effects on service availability and the relationship between clinicians and patients. Through various forms of pressure and incentives, managed care organizations or their representatives (e.g., carveouts) have reduced payments to providers and institutions, influenced length of hospital stays, limited patients' choices of physicians, and restricted patients' access to specialists. They have also imposed limitations on the availability of outpatient treatment sessions, decreased autonomy in treatment planning and perpetuated distinctions between coverage limits for mental disorders versus other medical illnesses. While the backlash to these changes has been intense (i.e., resulting in many states legislating patient bills of rights), the relationships between providers, patients and managed care companies continue to evolve.
In the midst of these ongoing changes in health care coverage and service delivery, suicidal patients continue to seek evaluation and treatment. In many cases, much can be done to help. Acute interventions with pharmacotherapy and psychotherapy can often reduce immediate pain and avert a tragic clinical outcome. Over the long term, we have medications such as lithium (Eskalith, Lithobid) and clozapine (Clozaril) and psychotherapies such as dialectical behavior therapy that can reduce suicide risk when used appropriately. Unfortunately, suicide continues to be a leading cause of death in the United States. According to the latest report from the National Center of Health Statistics, the 2000 suicide rate for the general population was 10.7 per 100,000, a slight decrease from a rate of 11.3 in 1998 (Centers for Disease Control and Prevention [CDC], 2002).
Suicide remains all too common among adolescents and ranks third among causes of death for individuals ages 10 to 24. The elderly, particularly white males, also account for many suicide deaths. Among adults ages 74 to 85, there are now 17.7 suicide deaths per 100,000 and, among adults 85 and over, the rate is 19.4 deaths per 100,000, well above the national average. This means that adults over 64 account for 12.4% of the population, but a full 18% of suicide deaths (CDC, 2002). These figures become especially salient when considering the aging U.S. population, the possibility for a greater overall incidence of suicide if elderly suicide rates continue at their relatively high level and the ongoing pressures on older adults to join managed care insurance plans.
While many critics of managed care express concern that an undue focus on cost savings must undermine the quality of clinical care, HMOs and PPOs possess certain features that conceivably could reduce their members' suicide rates. Health maintenance organizations increase the availability of health care by keeping insurance costs lower than they would otherwise be, enabling more employers to offer health care benefits to their employees. The more individuals who have access to health care services, the more likely mental illness will be diagnosed and treated. The risks of suicide are potentially mitigated by many HMOs' and PPOs' emphasis on preventive care, including coverage of routine physical exams and encouragement of mental health screenings that can identify individuals at risk for the mental illnesses that often precede suicide attempts.
Other HMO benefits that may help reduce the risk of suicide among members include prescription coverage, which significantly reduces the potentially prohibitive costs of medications that can treat psychiatric disorders and, in some cases, reduce suicide risk; provision of, or a requirement for, emergency coverage; a system for referral to specialists (although access may be limited); and systematic educational initiatives offered to providers. Some HMOs and PPOs have specifically offered training for their providers in the recognition of suicidal patients and the treatment of depression. One quality improvement intervention at a managed behavioral health care company led to an improvement in suicide risk assessment (Brown et al., 2003).
What is the actual outcome of this interplay of benefits and restrictions that may affect patients' vulnerability to suicide? Few studies have attempted to approach this difficult question. Related research, however, has examined the quality with which managed care organizations assess and treat patients with depression, a group particularly vulnerable to suicide (Halpern-Felsher et al., 2000). Wells and colleagues (1999) suggested that the rate and quality of care for depression were merely low to moderate in observed managed care primary practices, particularly for patients with severe but silent symptoms like suicidal ideation. These findings become all the more significant in light of the observation that half of adults who committed suicide saw their primary care physicians shortly before the act (Andersen et al., 2000; Diekstra and van Egmond, 1989).
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