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The current climate of managed care has dramatically changed how psychiatrists deal with the issue of suicide. What should clinicians know, both about the safety and welfare of their patients and to protect themselves legally, when dealing with managed care companies in cases of potential suicidality?
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).
The practices of managed care systems, however, must be compared with those of unmanaged care settings, where there is much variability of quality. A survey of pediatricians in a single HMO by Halpern-Felsher and colleagues (2000), for example, found that preventive services were provided to adolescent patients at rates below the HMO's recommendations, yet above the rates measured in other practice settings. The authors found that improvement was needed in the areas of preventive care that contribute most to adolescent mortality, including depression and suicide assessment, for which, respectively, only 46% and 35% of practitioners screened.
Provider education offered by HMOs and PPOs aims to reduce treatment variations, cut costs and standardize quality. Materials sponsored by managed care companies, however, are not uniformly welcomed by providers. Educational lessons, packaged as practice enhancements and/or evidence-based practice guidelines, are seen by some clinicians as tools that attempt to restrict practice options and discourage independence and creativity.
In a randomized trial of the effects of guideline dissemination, Azocar et al. (2003) found that the dissemination efforts of a managed behavioral health care organization failed to improve the adherence of mental health care clinicians to practice guidelines. Sharar and colleagues (in press), furthermore, surveyed executives and managers at managed behavioral health care organizations and concluded that the guidelines they prepare may lack objectivity and be subject to political pressures that affect their development.
Limitations on specialty referrals, sessions and medications all threaten to curtail the ability of the psychiatrist to care for the suicidal patient. Indeed, many clinicians who treat adolescents and who participated in a service provider survey perceived that not all of their desired psychiatric services were offered within the network (Yanos et al., 2003). Van Voorhees et al. (2003), in a questionnaire sent to primary care physicians, reported that a higher level of managed care market penetration was associated with lower perceived access to mental health services. In a review of the Massachusetts Behavioral Health program, then in its seventh year, the program was deemed an overall success, but not without its shortcomings (Beinecke and Vore, 2002). Providers complained of limited access, especially to inpatient and community residential programs, and were also worried about alarmingly short hospital and residential stays. Furthermore, the report cited a lack of coordination among state agencies, as well as lower than expected levels of integrated care. The latter was seen as a result of low or no reimbursement for collateral contacts (Beinecke and Vore, 2002). Sadly, all three reports suggest that managed care influences providers' perceived access to mental health care specialty providers--clinicians who should be made especially accessible in addressing a suicidal patient's crisis.
Patients with especially acute and intense risk for suicidal behavior are sometimes most safely and effectively cared for in inpatient settings, so managed care restrictions on access to inpatient care is perceived by clinicians as a particular concern. Some treatment systems that treat large numbers of patients insured by managed care systems have developed alternative outpatient programs to meet the needs of suicidal patients. Harney (2001) provided guidelines for clinicians trying to provide such alternatives to hospitalization and reported that one of the benefits of the managed care revolution has been the development and expansion of good outpatient services for suicidal patients. The benefit of such programs may provide some explanation for the observation that a 56% reduction in mandated state transfers to a psychiatric hospital in Fulton County, Ga., was not accompanied by any increase in the suicide rate (Garlow et al., 2002).
Administrative paperwork, used to justify payments and continued treatment, is an important aspect of managed care systems that impacts clinicians' treatment of suicidal patients. The added workload allows less time to spend with patients and strains the clinicians' ability to care for high-need patients, especially those who are suicidal (Beinecke and Vore, 2002; Yanos et al., 2003). The additional time-consuming task of bargaining with utilization managers for resources and treatment authorization adds significant time to the providers' job, often requiring unreimbursed additional hours of work.
In light of the ubiquitous presence of managed care in our current health care environment, some recommendations can be made for clinicians treating suicidal patients.
First, clinicians assessing new patients must not curtail the suicide evaluation process, including history of present illness, examination of mental state, and pertinent past and family history (Maltsberger, 1988). While time pressures imposed by managed care may tempt the practitioners to hurry the evaluation process and cut corners, the compressed treatment periods imposed by HMOs make accurate diagnosis--especially of suicide risk, substance abuse or psychosis--even more critical. At follow-up visits, clinicians must remain ready to explore changes in safety or suicide risk if warranted by any changes in a patient's circumstances, behavior or mental status.
Second, clinicians must make use of specialty services when necessary, including hospitals, partial hospitals and respite alternatives. While the least restrictive environment for effective care is preferred, there are times when a secure environment such as an inpatient unit remains necessary for ensuring a patient's safety.
Third, clinicians must know and remember that it is their responsibility to appeal the HMO's restrictions on treatment when these intolerably threaten a patient's safety. The legal onus for accurately assessing safety, suicide risk and the likelihood of other untoward outcomes, and planning appropriate care, lies squarely on the physician and not on the managed care company (Hall et al., 1999; Keyes, 2001).When there is a dispute between clinician and insurer, the clinician should not submit to a treatment plan that is unsafe.
In managed care systems that restrict psychiatrist visits to brief pharmacotherapy sessions or cut pharmacy costs by reducing the access barriers to large quantities of potentially toxic pharmaceuticals, clinicians should consider the suggestions listed in the Table.
Fourth, it is important to maintain patient safety and avoid overdosing by prescribing only the amount of medication appropriate. The cost-savings offered by 90-day mail-in prescriptions may be tempting to the patient and their managed care company, but are dangerous when careful monitoring of adherence is necessary. Likewise, changes in medical health and changes in the use of concurrent drugs or prescribed medications may alter the effects or safety of the psychopharmacology, making shorter-term prescriptions a better choice.
Fifth, in larger psychiatric settings, where mental health care is provided by a team, communication and documentation are paramount. Both from a legal and patient health perspective, it is required that team members make contemporaneous notes and also read the notes made by others. Similarly, recording the suicide risk assessment, documentation of family members' concerns and rationale for significant clinical decisions are all advisable. Keyes (2001) reminded clinicians that documentation does not remove the need for oral communication. Caregivers should speak to appropriate team members about serious concerns and document themappropriately.
Managed care has penetrated deeply into our health care system and is likely to remain with us for the foreseeable future. Therefore, we recommend that clinicians remain alert to the risks inherent in managed care while learning to make use of its potential resources. Further studies are needed to truly assess managed care's impact on suicide, and such studies must address the relative advantages and disadvantages presented by managed care in comparison to other health care payment systems.
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Azocar F, Cuffel B, Goldman W, McCarter L (2003), The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization. J Behav Health Serv Res 30(1):109-118.
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