Differences between generalists and mental health specialists in the psychiatric treatment of medicare beneficiaries

Objective. To examine differences between the general medical and mental he alth specialty sectors in the expenditure and treatment patterns of aged an d disabled Medicare beneficiaries with a physician diagnosis of psychiatric disorder. Data Sources. Based on 1991-1993 Medicare Current Beneficiary Survey data, linked to the beneficiary's claims and area-level data on provider supply f rom the Area Resources File and the American Psychological Association. Study Design. Outcomes examined included the number of psychiatric services received, psychiatric and total Medicare expenditures, the type of service s received, whether or not the patient was hospitalized for a psychiatric d isorder, the length of the psychiatric care episode, the intensity of servi ce use, and satisfaction with care. We compared these outcomes for benefici aries who did and did not receive mental health specialty services during t he episode, using multiple regression analyses to adjust for observable pop ulation differences. We also performed sensitivity;analyses using instrumen tal variables techniques to reduce the potential bias arising horn unmeasur ed differences in patient case mix across sectors. Principal Findings. Relative to beneficiaries treated only in the general m edical sector, those seen by a mental health specialist had longer episodes of care, were more likely to receive services specific to psychiatry, and had greater psychiatric and total expenditures. Among the elderly persons, the higher costs were due to a combination of longer episodes and greater i ntensity; among the persons who were disabled, they were due primarily to l onger episodes. Some evidence was also found of higher satisfaction with ca re among the disabled individuals treated in the specialty sector. However, evidence of differences in psychiatric hospitalization rates was weaker. Conclusions. Mental health care provided to Medicare beneficiaries in the g eneral medical sector does not appear to substitute perfectly for care prov ided in the specialty sector. Our study suggests that the treatment pattern s in the specialty sector may be preferred by some patients; further, earli er findings indicate geographic barriers to obtaining specialty care. Thus, the matching of service use to clinical need among this vulnerable populat ion may be inappropriate. The need for further: research on outcomes is ind icated.