Psychiatrists are reporting to APA’s Practice Research Network (PRN) that financial considerations have adversely affected the care they are able to provide for as many as one-third of their patients.

This is one of the critical practice-related findings reported by PRN Director Joyce West, Ph.D., M.P.P., at a symposium titled "What’s Really Going on in Psychiatry Today?: Update From the American Psychiatric Institute for Research and Education’s (APIRE) Practice Research Network" during APA’s Institute on Psychiatric Services in October. West discussed findings from the 1997 Study of Psychiatric Patients and Treatments that gathered information on access, patterns of care, and quality of care as reported by 417 psychiatrists who participated in the study.

For 34 percent of the 1,228 patients in the sample, said West, psychiatrists reported that financial considerations such as benefit limits, restrictions in public-sector care, and managed care rules "affected ‘optimal’ treatment as perceived by the psychiatrists."

West explained that these limitations resulted in a reduced number of patient visits for 23 percent of patients, a reduction in the length of the visit for 16 percent of the patients, and the need to provide a different form of treatment from the one the psychiatrist wanted for 15 percent of patients.

"For almost 9 percent of patients, the psychiatrist indicated the patient was prescribed a different medication from the one the psychiatrist would have preferred due to financial considerations," said West.

In addition, analyses revealed that of the 77 percent of the patients with a comorbid psychiatric disorder, 48 percent had a substance use disorder, and 44 percent had a personality disorder, said West. Patients with comorbid psychiatric disorders, substance abuse disorders, personality disorders, and psychosocial problems were more likely to have financial considerations affect treatment provisions, she said.

The researchers found that the health plan characteristics were also associated with having financial considerations affect treatment provision. Patients who were enrolled in managed behavioral health carveout plans and full service HMOs or PPOs had higher rates of having financial considerations alter the psychiatrists’ preferred mode of practice; only 23 percent of patients in nonmanaged plans were similarly affected, the psychiatrists said. Additionally, psychiatrists operating under performance-based incentives, including bonuses, withholds, or other financial incentives, reported that their patients’ treatment was affected adversely by the incentives and other managed care regulations.

Communication is another barrier to quality care for psychiatric patients, according to the PRN findings. Data show that 48 percent of psychiatrists do not receive any information from referring physicians before the patient’s first visit. In

addition, 37 percent of psychiatrists report that they have a poor or fair level of satisfaction with the communications with the general medical providers who refer patients to them.

"Future PRN research is being planned to assess the extent to which different types of financial or resource considerations such as insurance benefits, patient resources, or limits imposed through the management of benefits affect access to specific types of treatment," commented West.

Diane Herbeck, a PRN project manager, discussed findings from the 1999 Study of Psychiatric Patients and Treatments regarding race and ethnicity of the patients treated, as well as variations in psychiatric conditions, treatments, and health plan characteristics of these patients.

"There have been few studies at the national level about the delivery of mental health care in the U.S. to racially diverse populations, Herbeck noted, "and the research that exists is mixed." She explained that some studies have showed disparities in access to treatment between patients of different race and ethnicity, and other studies have found that most of the differences in access to care are diminished when factors such as socioeconomic status and financial coverage of health care are considered.

A total of 615 psychiatrists completed the 1999 PRN Study of Psychiatric Patients and Treatments providing data on 1,843 patients. Preliminary analysis showed that 77 percent of the patients in the sample were white, 10 percent African American, 7 percent Hispanic, and 5 percent Asian/Pacific Islanders.

"Clinically speaking," said Herbeck, "the 191 African-American patients in the sample were less likely to be diagnosed with mood or anxiety disorders and more likely to receive diagnoses of psychotic disorders." Additionally, according to PRN data, there were no differences between African-American, Hispanic, or white patients in the number of comorbid psychiatric disorders or general medical conditions diagnosed by physicians. Minority patients were considered to have more severe psychiatric impairments than nonminority patients, psychiatrists reported in the PRN survey.

"African-American patients were more likely to be seen in inpatient and partial hospital settings—and overall, the minority patients were less likely to be seen in office-based practices. Minority patients were also in treatment for fewer months than nonminority patients," said Herbeck.

In terms of treatments by psychiatrists, there were also some differences between white patients and minority patients—for example, minority patients were less likely to receive psychotherapy than white patients and more likely to receive medications alone, Herbeck said.

She noted that "while these data document similarities and differences between patients from different ethnic minority backgrounds and others nationwide, multivariate analyses controlling for socioeconomic status, clinical differences, and treatment must be done before we can draw definitive conclusions."