Provider choice and use of mental health care: Implications for gatekeepermodels

Objective. To examine the ways in which the costs of nonresidential mental health care depend on (1) the type of provider who initiates the treatment episode and (2) the level of cost sharing imposed on the patient. Study Setting. The 1987 National Medical Expenditure Survey, a national pro bability sample of the U.S. civilian, noninstitutionalized population. Data Collection. Data were collected during four personal interviews conduc ted during 1987 and 1988. Key variables include the type of provider contac ted at the beginning of treatment (psychiatrist other physician, nonmedical mental health care specialist) and the cost (total actual payments from al l sources) for the treatment episode. Methods of Analysis. An episodic model of demand for mental health care is estimated using a two-step procedure. Multinomial probit analysis is first used to determine the factors that influence the choice of initial provider type. Right-censored Tobit analysis is used to determine the factors that affect the costs of care, including the type of provider who initiates the care episode. Principal Findings. Results indicate that out-of-pocket price does signific antly (p < .05) affect the patient's initial choice of provider type but th at, after controlling for the endogeneity of provider choice, price is no l onger significant in explaining overall treatment costs. After controlling for selection effects, care episodes initiated by nonspecialist physicians are found to be as expensive as those initiated by psychiatrists and signif icantly more expensive than episodes initiated by nonphysicians. Conclusions. The results suggest that nonmedical mental health care special ists may be more effective than physicians in controlling costs when used a s case managers in the care of persons with mental illnesses.