Dr Robert London

Outpatient Care Made Better

Clinical Psychiatry News - Volume 32, Issue 10, Pages 32-33 (October 2004)

We've all been inundated with propaganda from insurance companies arguing that briefer patient encounters and care provided by people with less training are better for the patient—and the bottom line. But I've got a story to tell: Better care, as you will see, is cheaper than what is currently being offered. Just ask Dr. Carl Eisdorfer.

Dr. Eisdorfer, chairman of the department of psychiatry and behavioral sciences at the University of Miami, has helped to develop an outpatient mental health carve-out program in which experienced psychiatrists deliver direct, weekly treatments to the most seriously at-risk bipolar patients.

In his 9-year-old program, which has involved thousands of patients, he and his colleagues have come up with a wonderful model for better—and cheaper—mental health care.

The key points of managed care go something like this:

? Reduce costs by denying access.

? Use the least expensive professional available.

? Restrict the number of visits, sometimes to only five total visits per year.

? Provide a 1-800 telephone number staffed by a responder with a cookbook script for problems that occur.

Using the managed care approach, Dr. Eisdorfer and his colleagues found that costs mounted and care proved less than adequate. So they took an at-risk bipolar population that usually requires two to three hospitalizations per year and demonstrated that good outpatient care by experienced psychiatrists results in better care and lower costs.

Originally, Dr. Eisdorfer worked with a catchment group of patients in South Florida and found that, with experienced psychiatrists doing 40 outpatient visits per year with high-risk patients, the care—as measured by decreased hospitalizations—was better. In addition, the cost of care was significantly lower.

As this concept of better care became more refined, Dr. Eisdorfer and his colleagues focused on the 60 patients who required the most hospital days per year. As a way of encouraging visits, a telephone reminder system was put in place.

This group of 60 had a total of 171 admissions, which comes to 2.85 admissions per year per person. When those patients were given 40 outpatient visits per year, the number of admissions was reduced to 0.7 admissions per year per person. That is a total of 42 admissions per year, rather than 171. Bed days dropped from 771 to 168 days. The financial savings was tremendous, and the care was better.

The following hypothetical further illustrates my point. Let's say you saw a patient once a week at $100 a visit.

After factoring in vacations and cancellations, you might end up seeing the patient an average of 40 times per year, and that would amount to $4,000. In contrast, three hospitalizations per year, at two weeks per admission and $1,000 per day adds up to $42,000 a year. And that does not take into account the setback for the patient who might have to undergo an additional hospitalization.

So with the best care from psychiatrists, these high-risk patients get the best management at a lower cost: $4,000 a year instead of up to $42,000 a year.

What a revelation: People in the community receiving better care for less. This is good medical thinking, and the care is provided by psychiatrists who understand illness and patients' needs.

On the other hand, the provision of care by less-experienced clinicians is “in the box” economic thinking on a limited, day-to-day, cost-saving basis that, in my mother's words, is simply penny wise and pound foolish, not to mention costly in terms of pain and suffering. The message here is that more intensive care by qualified, experienced doctors doing outpatient work is better and more cost efficient.

The experienced psychiatrists in Dr. Eisdorfer's program are doing the psychopharmacology as well as the psychotherapy. This works better for these patients. The psychiatrist can pick up changes in illness patterns or social situations, make the proper changes, and avoid decompensation and subsequent hospitalization.

Clearly, many patients with less severe illness might benefit from less-intense combined therapy. Some mild to moderate depressions, for example, benefit not only from medicines, but from cognitive-behavioral therapy, behavioral therapy, or insight-oriented psychotherapy alone.

For those kinds of interventions and treatments, the psychiatrist's medical knowledge is not always necessary. Many nonmedical psychotherapists would agree. And often, those psychotherapists are often not comfortable with high-risk patients.

The Psychiatrist's Toolbox is a column dedicated to providing a forum for reflection on clinical experiences, treatment strategies, and education. As such, the column has a great responsibility to foster discussions about medical alternatives aimed at providing excellent and cost-efficient care for our patients.

Dr. Eisdorfer's model shows how we can do it. I'm sure that many medical and surgical models are out there that would provide better and more cost-efficient care if only managed care would get away from the kind of thinking that too often puts patients at greater risk. Most medicine and surgery patients feel the economic squeeze, but our patients feel it worse.

Unnecessary stereotypes remain in mental illness, and the patient population has a difficult time getting a voice for better care.

The work of Dr. Eisdorfer and his colleagues is a great beginning. We need to continue to do more in terms of better care at lower cost.

Let's hear your thoughts about ways to provide cost-efficient care. Please feel free to e-mail me at cpnews@elsevier.com, and I'll try to pass along your ideas to my readers.

PII: S0270-6644(04)70748-1

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