March 19, 1999

A new study has confirmed what psychiatrists have known for some time: integrated treatment makes not only clinical but also economic sense.

Contrary to managed care assumptions and practices, a psychiatrist can provide therapy with medication monitoring more cost-effectively than splitting treatment between a psychiatrist and a mental health professional.

The results of the study, which was reported in last month's American Journal of Psychiatry, show that a psychiatrist can provide 15 therapy sessions with medication monitoring for $216 less than when treatment is split between a psychologist for 15 therapy sessions and a psychiatrist for 10 medication visits ($1,331 versus $1,547).

Ten visits of integrated treatment by a psychiatrist was also about $88 less than 10 therapy visits with a psychologist and five medication visits with a psychiatrist ($893 versus $981). The same was true of five combined visits compared with five therapy sessions and three medication visits ($456 versus $544).

The author, Mantosh Dewan, M.D., a professor and interim chair of the department of psychiatry at the State University of New York at Syracuse, told Psychiatric News, "Psychiatrists are the only mental health practitioners who can provide primary mental health care and comprehensive biopsychosocial treatment. Interestingly, even as managed care organizations and HMOs set up primary care practices in general medicine, they did the very opposite in mental health-they fragmented the system!"

Dewan noted that it is better for the patient to deal with one mental health professional and to manage appointments because of less time away from work, lower expenses, and less travel.

The results also showed that a psychiatrist can provide 15 combined sessions for $61 less than a social worker for 15 therapy sessions and a psychiatrist for five medication visits.

Norman Clemens, M.D., Area 4 Trustee and chair of APA's Commission on Psychotherapy by Psychiatrists, commented to Psychiatric News, "I am delighted that this additional study shows that managed care companies are practicing false economies when they engage in split treatment."

This study augments the findings of Goldman and colleagues reported in last April's Psychiatric Services showing that those receiving integrated treatment used significantly fewer outpatient sessions and had significantly lower treatment costs than patients in split treatment ($1,336 versus $1,854), noted Clemens.

"When studies of clinical outcome are available, I suspect they will show similar trends," he commented.

The results also showed that medication management alone (that is, without therapy) by a psychiatrist was the least expensive modality compared with therapy only by a social worker, psychologist, or psychiatrist.

"Sparsely monitored medication management (three or five visits) is increasingly favored by managed care organizations," said the author.

When medication costs (approximately $720 for the newer antidepressants) are added in, however, treatment with medication alone becomes more expensive than short-term psychotherapy alone by a social worker ($299 for five sessions, $598 for 10 sessions).

Clemens commented, "These studies are further evidence that MCOs are really interested in this quarter's bottom line, not in ultimate cost savings to the community. There is abundant evidence that psychiatric treatment including psychotherapy not only cuts medical costs for patients and their families, but reduces absenteeism and job turnover and increases productivity."

Dewan calculated the costs for the study's treatment scenarios based on 1998 payment schedules from seven large managed care organizations in central New York with a combined 1996 market share of 68 million covered lives, or 54 percent.

The author suggested that depressed patients with Hamilton Depression Rating Scale scores above 20 be referred to a psychiatrist for antidepressant therapy with optional adjunctive psychotherapy. "However, managed care organizations preferentially refer all patients to nonpsychiatrist therapists first, with the option of medication evaluation later. This may delay effective treatment."

Dewan recommended that future workforce estimates be revised based on the assumption that psychiatrists provide psychotherapy as a part of integrated treatment to large numbers of seriously ill patients, which is what they currently do.

Because the payment schedules were limited to central New York and vary by year, region, and managed care organization, the author said randomized quantitative studies are needed to compare the effectiveness and cost-efficiency of integrated treatment and split treatment.

"If findings of such studies support the cost-effectiveness of integrated treatment, psychiatry could vigorously advocate for the integrated biopsychosocial model on both theoretical and economic grounds," stated the author.-C.L.