Department of Psychiatry II, Ulm University, Ulm, Germany
Background There is limited evidence on the course of health service costs before and after psychiatric inpatient treatment, which might also be affected by source of cost data. Thus, this study examines: i) differences in health care costs before and after psychiatric inpatient treatment, ii) whether these differences vary by source of cost-data (self-report vs. administrative), and iii) predictors of cost differences over time.
Methods Sixty-one psychiatric inpatients gave informed consent to their statutory health insurance company to provide insurance records and completed assessments at admission and 6-month follow-up. These were compared to the self‐reported treatment costs derived from the “Client Socio-demographic and Service Use Inventory” (CSSRI‐EU) for two 6‐month observation periods before and after admission to inpatient treatment to a large psychiatric hospital in rural Bavaria. Costs were divided into subtypes including costs for inpatient and outpatient treatment as well as for medication.
Results Sixty-one participants completed both assessments. Over one year, the average patient‐reported total monthly treatment costs increased from € 276.91 to € 517.88 (paired Wilcoxon Z = ‐2.27; P = 0.023). Also all subtypes of treatment costs increased according to both data sources. Predictors of changes in costs were duration of the index admission and marital status.
Conclusion Self-reported costs of people with severe mental illness adequately reflect actual service use as recorded in administrative data. The increase in health service use after inpatient treatment can be seen as positive, while the pre-inpatient level of care is a potential problem, raising the question whether more or better outpatient care might have prevented hospital admission. Findings may serve as a basis for future studies aiming at furthering the understanding of what to expect regarding appropriate levels of posthospital care, and what factors may help or inhibit post-discharge treatment engagement. Future research is also needed to examine long-term effects of inpatient psychiatric treatment on outcome and costs.
1. Leslie DL, Rosenheck R. Shifting to outpatient care? Mental health care use and cost under private insurance. Am J Psychiatry 1999; 156: 1250-7.
2. Kilbourne AM, Greenwald DE, Bauer Mark S, Charns MP, Yano EM. Mental health provider perspectives regarding integrated medical care for patients with serious mental illness. Adm Policy Ment Health 2012; 39: 448-57. doi: 10.1007/s10488-011-0365-9
3. Chi FW, Parthasarathy S, Mertens JR, Weisner CM. Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model. Psychiatr Serv 2011; 62: 1194-200. doi: 10.1176/appi.ps.62.10.1194
4. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend 2009; 99: 280-95. doi: 10.1016/j.drugalcdep.2008.08.003
5. Druss BG, von Esenwein SA, Compton MT, Rask KJ, Zhao L, Parker RM. A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study. Am J Psychiatry 2010; 167: 151-9. doi: 10.1176/appi.ajp.2009.09050691
6. Butler M, Kane RL, McAlpine D, Kathol RG, Fu SS, Hagedorn H, et al. Integration of mental health/substance abuse and primary care. Rockville (MD): Agency for Healthcare Research and Quality; 2008.
7. Zubkoff L, Young-Xu Y, Shiner B, Pomerantz A, Watts BV. Usefulness of symptom feedback to providers in an integrated primary care-mental health care clinic. Psychiatr Serv 2012; 63: 91-3. doi: 10.1176/appi.ps.201100323
8. Chiverton P, Tortoretti D, LaForest M, Walker PH. Bridging the gap between psychiatric hospitalization and community care: cost and quality outcomes. J Am Psychiatr NursesAssoc 1999; 5: 46-53. doi: 10.1016/S1078-3903(99)90019-8
9. Tulloch AD, Fearon P, David AS. Length of stay of general psychiatric inpatients in the United States: systematic review. Adm Policy Ment Health 2011; 38: 155-68. doi: 10.1007/s10488-010-0310-3
10. Rentmeester CA. Challenges for policy makers and organizational leaders: addressing trends in mental health inequalities. Int J Health Policy Manag 2013; 1: 99-101. doi: 10.15171/ijhpm.2013.16
11. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med 2011; 24: 229-39. doi: 10.3122/jabfm.2011.03.100170
12. Parthasarathy S, Mertens J, Moore C, Weisner C. Utilization and cost impact of integrating substance abuse treatment and primary care. Med Care 2003; 41: 357-67.
13. Chisholm D, Sekar K, Kumar KK, Saeed K, James S, Mubbashar M, et al. Integration of mental health care into primary care. Demonstration cost-outcome study in India and Pakistan. Br J Psychiatr 2000; 176: 581–8.
14. Mitton CR, Adair CE, McDougall GM, Marcoux G. Continuity of care and health care costs among persons with severe mental illness. Psychiatr Serv 2005; 56: 1070-6. doi: 10.1176/appi.ps.56.9.1070
15. Salize HJ, Rössler W, Becker T. Mental health care in Germany: current state and trends. Eur Arch Psychiatry Clin Neurosci 2007; 257: 92-103. doi: 10.1007/s00406-006-0696-9
19. Olfson M, Sing M, Schlesinger HJ. Mental health/medical care cost offsets: opportunities for managed care. Health Aff 1999; 18: 79-90. doi: 10.1377/hlthaff.18.2.79
20. Kocakülah MC, Valadares KJ. Cost offset effect strategies for the provision of mental health care services. J Health Care Finance 2003; 30: 31-40.
21. Mumford E, Schlesinger HJ, Glass GV, Patrick C, Cuerdon T. A new look at evidence about reduced cost of medical utilization following mental health treatment. Am J Psychiatry 1984; 141: 1145-58.
22. Chiles JA, Lambert MJ, Hatch AL. The impact of psychological interventions on medical cost offset: a meta-analytic review. Clin Psychol Sci Pract 1999; 6: 204-20. doi: 10.1093/clipsy.6.2.204
23. Katon W, Unutzer J, Fan MY, Williams JW Jr, Schoenbaum M, Lin EH, et al. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care 2006; 29: 265-70. doi: 10.2337/diacare.29.02.06.dc05-1572
24. Fifer SK, Buesching DP, Henke CJ, Potter LP, Mathias SD, Schonfeld WH, et al. Functional status and somatization as predictors of medical offset in anxious and depressed patients. Value Health 2003; 6: 40-50. doi: 10.1046/j.1524-4733.2003.00148.x
25. Holder HD, Blose JO. Changes in health care costs and utilization associated with mental health treatment. Hosp Community Psychiatr 1987; 38: 1070–5.
26. Maynard C, Cox GB, Krupski A, Stark K. Utilization of services for mentally ill chemically abusing patients discharged from residential treatment. J Behav Health Serv Res 1999; 26: 219-28. doi: 10.1007/BF02287493
27. Gater R, Goldberg D, Jackson G, Jennett N, Lowson K, Ratcliffe J, et al. The care of patients with chronic schizophrenia: a comparison between two services. Psychol Med 1997; 27: 1325-36. doi: 10.1017/S0033291797005631
28. Zentner N, Baumgartner I, Becker T, Puschner B. Kosten medizinischer Leistungen bei Menschen mit schweren psychischen Erkrankungen: Selbstbericht vs. Kostenträgerangaben [Health service costs in people with severe mental illness: patient report vs. administrative records]. Psychiatr Prax 2012; 39: 122-8. doi: 10.1055/s-0031-1298869.
30. Roick C, Kilian R, Matschinger H, Bernert S, Mory C, Angermeyer MC. Die deutsche Version des Client Sociodemographic and Service Receipt Inventory: Ein Instrument zur Erfassung psychiatrischer Versorgungskosten [German adaptation of the Client Sociodemographic and Service Receipt Inventory - an instrument for the cost of mental health care]. Psychiatr Prax 2001; 28: 84-90. doi: 10.1055/s-2001-17790
31. Chisholm D, Knapp MR, Knudsen HC, Amaddeo F, Gaite L, van Wijngaarden B. Client Socio-Demographic and Service Receipt Inventory-European Version: development of an instrument for international research. EPSILON Study 5. Br J Psychiatr Suppl 2000; 177: S28. doi: 10.1192/bjp.176.6.581
32. World Health Organization (WHO). International Statistical Classification of Diseases and Related Health Problems, 10th Revision. 2005. [cited 2014 Aug 7]. Available from: http://apps.who.int/classifications/apps/
33. Lambert MJ, Hannöver W, Nisslmüller K, Richard M, Kordy H. [Questionnaire on the results of psychotherapy: reliability and validity of the German translation of the Outcome Questionnaire 45.2 (OQ-45.2)]. Z Klin Psychol 2002; 1: 40-7. doi: 10.1026//1616-34126.96.36.199
34. Puschner B, Cosh S, Becker T. Patient-rated outcome assessment with the German version of the Outcome Questionnaire 45 in people with severe mental illness. Eur J Psychol Assess 2014: in press.
35. Lambert MJ, Burlingame GM, Umphress VJ, Hansen NB, Vermeersch DA, Clouse G, et al. The reliability and validity of the Outcome Questionnaire. Clin Psychol Psychother 1996; 3: 106-16.
38. Krauth C, Hessel F, Hansmeier T, Wasem J, Seitz R, Schweikert B. [Empirical standard costs for health economic evaluation in Germany - a proposal by the working group methods in health economic evaluation]. Gesundheitswesen 2005; 67: 736-46. doi: 10.1055/s-2005-858698
39. Bavarian Association of Statutory Health Insurance Physicians. Honorarvertrag zwischen der KVB und der AOK Bayern 2006/2007 [Fee agreement between the Bavarian Association of Statutory Health Insurance Physicians and the AOK Bavaria]. 2006. [cited 2014 Aug 7]. Available from: http://www.kvb.de/fileadmin/kvb/dokumente/Praxis/Rechtsquellen/
40. National Association of Statutory Health Insurance Physicians. Einheitlicher Bewertungsmaßstab EBM, Stand 2008 - 4. Quartal [Uniform physicians' fee schedule]. 2008. [cited 2014 Aug 7]. Available from: http://www.kbv.de/media/EBM-2008-Archiv.zip
41. Rote Liste Service. Rote Liste: Arzneimittelverzeichnis für Deutschland [Red List: list of pharmaceuticals in Germany]. Frankfurt/Main: Rote Liste; 2007.
42. Kilian R, Matschinger H, Loeffler W, Roick C, Angermeyer MC. A comparison of methods to handle skew distributed cost variables in the analysis of the resource consumption in schizophrenia treatment. J Ment Health Policy Econ 2002; 5: 21-31.
43. Haberfellner EM, Grausgruber A, Grausgruber-Berner R, Ortmair M, Schony W. Die Enthospitalisierung ehemaliger psychiatrischer Langzeitpatienten in Oberösterreich - Inanspruchnahme von Versorgungsleistungen und Kosten der außerstationären Versorgung [Deinstitutionalization of long-stay psychiatric patients in upper Austria - utilization of healthcare resources and costs of outpatient care]. Psychiatr Prax 2006; 33: 74-80. doi: 10.1055/s-2004-828397
45. Stargardt T, Edel MA, Ebert A, Busse R, Juckel G, Gericke CA. Effectiveness and cost of atypical versus typical antipsychotic treatment in a nationwide cohort of patients with schizophrenia in Germany. J Clin Psychopharmacol 2012; 32: 602-7. doi: 10.1097/JCP.0b013e318268ddc0
46. Newcomer JW. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs 2005; 19: 1-93. doi: 10.2165/00023210-200519001-00001
47. Lang FH, Forbes JF, Murray GD, Johnstone EC. Service provision for people with schizophrenia. I. Clinical and economic perspective. Br J Psychiatr 1997; 171: 159-64. doi: 10.1192/bjp.171.2.159
48. Merkesdal S, Bernitt K, Busche T, Bauer J, Mau W. Gegenüberstellung der Krankheitskosten im Jahr vor und nach stationärer und ambulanter Rehabilitation bei Personen mit Dorsopathien [Comparison of Costs-of-illness in patients with low back pain 12 months prior and after orthopaedic inpatient and outpatient rehabilitation]. Rehabiliation 2004; 43: 83–9. doi: 10.1055/s-2003-814823
49. Raven MC, Doran KM, Kostrowski S, Gillespie CC, Elbel BD. An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study. BMC Health Serv Res 2011; 11: 270. doi: 10.1186/1472-6963-11-270