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Linkages Between Primary Care Physicians and Mental Health Specialists.

Primary care physicians (PCPs) are integral to the provision of mental health (MH) services. Linkages between PCPs and MH providers are a vital component of care for psychiatric patients. This paper reports on an exploratory survey of PCPs about their relationships with mental health specialists.

PCPs affiliated with Jefferson Medical College in Philadelphia, Pennsylvania were surveyed on the nature and quality of consultation and referral practices they had with individual mental health providers and mental health carve-out organizations. The survey was based on published literature regarding collaboration in health-related and non health-related organizational settings.

Ninety-nine attending physicians responded to the survey. Physicians' ability to treat MH patients was positively related to the availability of MH consultation (p=.029). 48.5% of PCPs reported never/ seldom providing information to MH carve-outs, compared to 16.2% to individual MH providers (p=.001). Receipt of patient information back from MH providers was poor-54.4% reported never/seldom receiving information back from MH carve-outs, compared to 47.1% from individual MH providers (p=.521). 66.7% of PCPs were never/seldom satisfied with their consultation and referral relationships with MH carve-outs, compared with 34.8% never/seldom satisfied with individual MH providers (p. 001). Quality of mental health care was perceived to be lower for patients who were referred to mental health carve-out programs compared to those referred to individual mental health providers (55.7% fair/poor for MH carve-outs vs. 11.4% for individual providers, p=.001).

This pilot study points to differences in collaborative relationships and the necessity of increased communication between primary care and mental health providers, especially in settings where primary care providers refer to mental health carve-out programs. Future research may seek to survey more diverse groups of physicians and investigate how collaborative arrangements impact upon patient outcomes.

Fam Syst & Health 17:295-307, 1999

Primary care physicians are integral to the provision of mental health services. Nationwide, primary care physicians see an estimated 50% of those with mental disorders, and for patients with mental health problems, the primary care physician (PCP) is often the first, and sometimes the only physician who treats them (Regier, 1993). At the same time, PCPs may vary in their ability to diagnose and treat patients with mental health problems (Kessler et al., 1985). Studies have assessed to what degree PCPs are prepared to diagnose and treat these patients (Katon et al., 1992), as well as described relationships that PCPs have with mental health specialists (Bray and Rogers, 1995; Fischer et al., 1997; Gavin et al., 1998). In this era of managed care, the PCP's role includes responsibility as a "gatekeeper" who diagnoses, treats patients as well as refers them to specialists when necessary (Grumbach and Fry, 1993). Because of PCPs' central role in providing healthcare services, they may detect and manage episodic mental disorders as well as become "case managers" for chronically ill patients (DeGruy, 1996; Starfield, 1992). This paper reports on a survey of PCPs on their relationships with mental health (MH) specialists in managed care and non-managed care arrangements.

Linkages between PCPs and MH specialty providers facilitate the coordination, continuity, and quality of MH care (Miller and Luft, 1993), and allow for more timely identification and treatment of psychiatric problems (Olfson, 1991). Simply shifting responsibilities for mental health care to the PCP is not likely to improve care (Sturm and Wells, 1995). Rather, PCPs are often key members of the collaborative team that manages patients and families who are resource intensive and whose problems may span medical, psychiatric, and social domains (Doherty, 1995; McDaniel, 1995).

PCP/MH provider collaboration may be associated with more timely MH care, where treatment is in more appropriate, yet less intensive and less expensive care settings (Sharfstein and Katz-Levy, 1984). More timely care may avert direct and indirect costs of psychiatric morbidity and mortality, and reduce expenses for general medical care (Jones and Vischi, 1987; Pincus, 1984; Pincus, 1990; Richman, 1990; Shuster, 1992). Savings have been reported from treatment in less intensive mental health settings, such as those found in health maintenance organizations, where MH costs have been found to be lower (Diehr et al., 1984; Norquist and Wells, 1991; Shadle and Christianson, 1988; Shadle and Christianson, 1989; Wells et al., 1986). In a pilot study of patients in two rural HMOs, we found that patients in the primary care site which had weaker mental health consultative linkages had more mental health hospital utilization as well as higher overall healthcare costs (Yuen et al., 1996).

Two key factors that may affect PCP/MH specialist relationships are financing and organizational mechanisms (Roulidis and Schulman, 1994). PCPs have been increasingly required to refer patients to mental health carve-outs, organizations that subcontract with the patient's insurance company for the exclusive provision of mental health care. While mental health carve-out organizations, which are often based within capitated insurance systems, may be more efficient and less costly in treating patients with mental health problems (Frank et al., 1996; Wells et al., 1995), these organizations may also affect the nature and quality of PCP/ MH linkages. Potentially adverse effects upon these PCP/MH linkages include care fragmentation; less comprehensive evaluation of the patient's condition; and duplication in resource use (Fischer and Ransom, 1997). Some managed care organizations have alternatively chosen to move towards "carved-in" approaches which de-emphasize specialization and instead espouse mutual respect for the unique contributions that each professional of a multi-specialty group may bring to collaboration around patient care (Slay and Glazer, 1995; McDaniel et al., 1992).

Additional study is called for in the nature and quality of MH/PCP collaboration in carve-outs as these types of insurance arrangements proliferate (Pincus et al., 1996). Mechanisms within managed care that facilitate, rather than discourage communication, need to be identified. Case studies have demonstrated collaborative relationships within managed care settings (Olsen et al., 1995), and these arrangements should be tested in other venues.

Dimensions of PCP/MH Linkage

The linkage process--the communication and collaboration between PCP and MH providers--affects how well patients' clinical and behavioral needs are addressed over time. Inadequate or incomplete communication or collaboration may adversely affect patient access to care, timeliness of care, treatment continuity, and ultimately patient outcomes. Many authors have hypothesized models which describe dimensions of PCP/MH linkage. An overview of existing linkage conceptualizations is essential to understand and evaluate which care processes ultimately affect clinical and financial outcomes. Below we outline models that move from a macro-organizational level to the individual provider level.

Some models of linkage between PCPs and MH providers describe key organizational dimensions. Dolinar (Dolinar, 1993) outlined health service delivery systems where linkage relationships may be shaped by organizational and locational factors. Location of care has long been recognized as an important variable, and may be categorized as to whether: 1) MH care was provided within a comprehensive medical clinic; 2) there was consultation and/or referral by PCPs to other outpatient MH settings, but rarely joint care of the patient; 3) there were stand-alone MH clinics where treatment, but not consultation with PCPs was common; and 4) there were stand-alone MH consultation clinics. Policy and planning environments may also determine the nature of PCP/MH provider linkages. Federal/state legislation; financing and funding entities; and/or governing board structures have the ability to facilitate (or inhibit) integration between PCPs and MH providers (Bird et al., 1995) through their organizational and administrative oversight.

Interactions that transpire between PCP and MH providers also account for variance in care. Pincus' (Pincus, 1987) models of linkage emphasize care processes and include the following dimensions: 1) who the providers are (i.e. family physician, psychiatrist, social worker); 2) what the relationship between the providers is (i.e. is it joint care, consultation, referral, or independent care?); and 3) when during patient care communication between the PCP and MH providers takes place (i.e. is it during patient diagnosis/assessment, short term management, or long term management?)

Doherty has described the attributes and the nature of these collaborative relationships between generalists and MH specialists with more texture (Doherty, 1995). He hypothesized five levels of collaboration that describe both physical settings as well as the nature of communication within those settings. His levels ranged from "minimal collaboration," where there are no shared facilities or information systems to "close collaboration," where providers shared facilities, information systems and charts, as well as held regular meetings to discuss patients and treatment goals.

McDaniel et al. (McDaniel, 1995) have described effective collaboration arrangements between PCPs and psychologists, and have underlined the importance of a collaborative team sharing a common biopsychosocial model of their patients and families. Inherent in this model is the belief that physical illnesses have psychosocial consequences, and that psychological problems have physiological manifestations. To address patients' problems in a holistic fashion, expertise from both primary care physicians and MH specialists are necessary.

Last but not least, individual physician attributes contribute to the nature of PCP/ MH linkage relationships (McDaniel et al., 1992). Individual characteristics include demographics (i.e. age, years in practice, job stress, physician work load); physician beliefs and practice style (especially beliefs about stigma, cause of symptoms; sensitivity to MH issues, style of interviewing); different cultures inherent within PCP and MH professional training; as well as physician practice structure (such as the size and resources of practice, comfort with collaboration, specialty, cultural, community interests). These factors affect the degree to which PCPs establish linkage relationships with MH providers, as well as the nature of those relationships.

Goals of this study

While these proposed linkage models provide conceptual lenses through which to view PCP/MH provider relationships and patient care, research is just beginning regarding collaboration and referral in managed care settings. We are early in the process of understanding how managed care organizational and financial structures impact upon collaboration, patient care, quality, and cost (Gonzales, 1995). This exploratory study describes collaborative and referral relationships between PCPs and MH providers in managed care and non-managed care arrangements. The following issues were considered:

* Was there a relationship between the availability of MH personnel and PCPs' ability to recognize and treat mental disorders?

* Did PCPs perceive differences between MH managed care and non-managed care providers regarding exchange of clinical information, satisfaction with the relationship, and quality of care?

* What difficulties could be expected in conducting this type of research?

Methods

PCPs affiliated with Jefferson Medical College (Family Medicine and General Internal Medicine practitioners) were surveyed on the nature and quality of consultation and referral practices they had with MH individual providers and carve-out organizations. The survey aimed to examine both structural and process characteristics of these PCP/MH specialty relationships that may affect patient outcomes. Other components of the survey collected demographic and work environment information, and the self-reported ability of the surveyed generalist practitioner to recognize and treat specific mental health problems. Lastly, questions asked about dimensions of PCP/MH collaboration, focusing on comparisons between individual MH providers and MH carve-out programs. Mental health carve-outs were defined as "organizations that subcontract with the patient's insurance company for the exclusive provision of mental health care."

The survey was developed through roundtable discussions with clinicians from the Departments of Family Medicine and Psychiatry at Jefferson Medical College, Penn State Geisinger Medical Center, and Georgetown University. The survey was based on the published literature regarding collaboration in health-related and non health-related organizational settings and included topics and items that these practicing clinicians thought were important in the quantification of consultation and referral relationships between PCPs and MH specialists. A number of questions contrasted relationships between individual MH providers and MH carve-out organizations (1). Prior to its circulation among clinicians affiliated with Jefferson Medical College, the survey was tested on four physician-researchers at Jefferson who contributed suggestions regarding length, format, clarity, and ease of completion.

The survey was circulated anonymously to attending physicians, fellows, residents, and interns affiliated with the Departments of Family Medicine (FM) and General Internal Medicine (IM) at Jefferson Medical College, located in Philadelphia, Pennsylvania. A total of 263 attending physicians and 145 fellows, residents, and interns were surveyed. Because the sampling time frame spanned the academic year, resulting in fellows/ interns/residents' responses being lost to follow-up, only results from the attendings' survey are reported here.

Attending physicians included those who were on the faculty and staff of Jefferson Medical College (JMC) and who practiced in an academic setting (21.3%, n=56), as well as physician affiliates who participated in residency placement programs with JMC but whose clinical practices were located in community settings (78.7%, n=207). The survey was sent out with a cover letter from the chairpersons of the respective departments, explaining its purpose. A follow-up survey was sent out to all attending physicians in the sample a few months later.

For analysis, chi-square statistical test was used for categorical variables, incorporating Fischer's exact test when the expected cell size was [is less than] 5. To test agreement between pairs of questions with categorical responses, Bowker's test for symmetry was used. T-tests were used to test differences in means of continuous variables. Comparisons between managed care and non-managed care providers included only those providers whose patients were insured in a mandated mental health (MH) treatment network or MH carve-out.

Results

One hundred and nine attending physicians responded to the survey (response rate=41.4%). Physicians who were not board certified in Family Medicine or General Internal Medicine were excluded (n=10), resulting in an analytic sample of 99 physicians. The mean age of respondents was 45.7 years, and 25.2% of them were female. Respondents averaged 16.5 years in practice. Physicians reported that they worked most frequently in private group practice or as hospital employees. Outpatient offices were by far the most frequent location where physicians saw patients, followed by hospital locations; very little time was spent in either emergency rooms or in chronic care facilities. On average, physicians reported 28.7% of their patients seen over the last year had MH problems, although this percentage ranged from 3% to 80%; while 18.2% reported that under 15% of their patients had MH problems, 13.1% reported that over 50% had MH problems (2). 11.6% were insured by Medicaid, and 29.5% were insured by Medicare. 61.6% of the physicians reported having no availability of on-site mental health consultation at all (Table 1). Physicians reported having a wide range of exposure to mental health carve-out organizations, on average physicians reported that 44.4% of their patients were insured by MH carve-outs. While 17.2% of patients had no exposure to MH carve-outs at the time of the survey, over half of the physicians reported having over 50% of their patients insured by MH carve-outs, and 14 physicians reported that 80% or more of their patients were insured by MH carve-outs (Table 1).
TABLE 1 Description of Study of Population

Age (mean, std.)                                        45.7 (12.0)
Gender (% male)                                         74.8%
Years in Practice (mean, std.)                          16.5 (11.8)
Patients per week (mean, std.)                          81.4 (48.1)

Percentage of patients with MH problems (mean, std.)    28.7 (18.1)
Percentage of patients insured by MH carve-out
 organizations (mean, std.)                             44.4 (30.0)

Hours per week in the following settings (mean, std.)
  Solo practice                                          5.3 (14.3)
  With one physician                                     1.2 (6.3)
  Private group practice                                13.2 (18.4)
  Hospital employee                                     10.4 (17.1)
  HMO employee                                           0.6 (3.9)
  Other setting                                          2.2 (6.9)

On Site Availability of MH Consultation (N, %)
  Daily                                                 13 (13.1%)
  3-4 days/week                                         11 (11.1%)
  1-2 days/week                                          5 (5.1%)
  On call                                                6 (6.1%)
  None                                                  61 (61.6%)
  Do not know                                            3 (3.0%)


Overall, two-thirds of attending physicians rated their ability to recognize mental illness as very good or excellent, but about half that many rated their ability to treat mental illness as very good or excellent. Physicians' ability to recognize mental illness was not related to the availability of mental health consultation. However, physicians' ability to treat mental illness was positively related to the availability of MH consultation (Table 2).

TABLE 2 Ability to Recognize and Treat Mental Illness and On-Site Availability of MH Services
                                     Very Good/
                                     Excellent    Good

Ability to recognize compared
to ability to treat mental illness
   Ability to recognize              66 (66.7%)   31 (31.3%)
   Ability to treat                  37 (37.3%)   45 (45.5%)

Ability to recognize
   Any availability of MH            26 (74.3%)   9 (25.7%)
   No availability of MH             40 (62.5%)   22 (34.4%)

Ability to treat
   Any availability of MH            18 (51.4%)   15 (42.9%)
   No availability of MH             19 (29.7%)   30 (46.9%)

                                     Fair/Poor    P-value

Ability to recognize compared
to ability to treat mental illness                .001(*)
   Ability to recognize              2 (2.0%)
   Ability to treat                  17 (17.2%)

Ability to recognize                              .349(**)
   Any availability of MH            0 (0.0%)
   No availability of MH             2 (2.0%)

Ability to treat                                  .029(**)
   Any availability of MH            2 (5.7%)
   No availability of MH             15 (23.4%)


(*) Bowker's test for symmetry measuring classification agreement between 2 responses (ability to recognize vs. ability to treat)

(**) Chi-square test comparing ability to recognize/treat and availability of MH

In terms of information exchange, nearly half of the physicians seldom or never provided information to MH carve-outs, while only 16.2% never or seldom provided information to individual MH providers. Over half of physicians reported seldom or never receiving information back from carve-out programs, and nearly the same percentage did not receive information back from individual mental health providers (Table 3).

TABLE 3 Information Exchange, Satisfaction, and Quality of MH Care Between Primary Care and Types of Mental Health Providers
                                                     With
                                                   Individual
                                                    Providers

Do you provide information on referred patients?
  Often/Always                                     33 (48.5%)
  Sometimes                                        24 (35.3%)
  Never/Seldom                                     11 (16.2%)

Do you receive information on referred patients?
  Often/Always                                     17 (25.0%)
  Sometimes                                        19 (27.9%)
  Never/Seldom                                     32 (47.1%)

Are you satisfied with your referral and
consultation relationship(s)?
  Often/Always                                     21 (30.4%)
  Sometimes                                        24 (34.8%)
  Never/Seldom                                     24 (34.8%)

Compared to other clinical specialties, are you
satisfied with referral and consultation relationships?
  Often/Always                                     16 (22.9%)
  Sometimes                                        16 (22.9%)
  Never/Seldom                                     38 (54.2%)

What is your perception of the quality of mental
health care that your patients receive?
  Very good/Excellent                              35 (50.0%)
  Good                                             27 (38.6%)
  Fair/Poor                                        8 (11.4%)

Overall, how well do you think that the mental
health needs of the patient and family are being
met in your practice?
  Very good/Excellently                            25 (36.2%)
  Good                                             31 (44.9%)
  Fair/Poor                                        13 (18.9%)

                                                      With
                                                 Mental Health
                                                   Carve-outs

Do you provide information on referred patients?
  Often/Always                                     21 (30.9%)
  Sometimes                                        14 (20.6%)
  Never/Seldom                                     33 (48.5%)

Do you receive information on referred patients?
  Often/Always                                     18 (26.5%)
  Sometimes                                        13 (19.1%)
  Never/Seldom                                     37 (54.4%)

Are you satisfied with your referral and
consultation relationship(s)?
  Often/Always                                     7 (10.1%)
  Sometimes                                        16 (23.2%)
  Never/Seldom                                     46 (66.7%)

Compared to other clinical specialties, are you
satisfied with referral and consultation relationships?
  Often/Always                                     5 (7.1%)
  Sometimes                                        12 (17.2%)
  Never/Seldom                                     53 (75.7%)

What is your perception of the quality of mental
health care that your patients receive?
  Very good/Excellent                              11 (15.7%)
  Good                                             20 (28.6%)
  Fair/Poor                                        39 (55.7%)

Overall, how well do you think that the mental
health needs of the patient and family are being
met in your practice?
  Very good/Excellently                            12 (17.4%)
  Good                                             21 (30.4%)
  Fair/Poor                                        36 (52.2%)

                                                             P-
                                                          value(*)

Do you provide information on referred patients?            .001
  Often/Always
  Sometimes
  Never/Seldom

Do you receive information on referred patients?            .521
  Often/Always
  Sometimes
  Never/Seldom

Are you satisfied with your referral and
consultation relationship(s)?                               .001
  Often/Always
  Sometimes
  Never/Seldom

Compared to other clinical specialties, are you
satisfied with referral and consultation relationships?     .001
  Often/Always
  Sometimes
  Never/Seldom

What is your perception of the quality of mental
health care that your patients receive?                     .001
  Very good/Excellent
  Good
  Fair/Poor

Overall, how well do you think that the mental
health needs of the patient and family are being
met in your practice?                                       .001
  Very good/Excellently
  Good
  Fair/Poor


(*) Bowker's test for symmetry measuring classification agreement between 2 responses (individual providers vs. MH carve-outs)

Two-thirds of the respondents were sometimes, often, or always satisfied with their consultation and referral relationships to individual mental health providers, but only one-third were sometimes, often, or always satisfied with their relationships to mental health carve-out programs. This difference held up even when physicians were asked to rank their satisfaction compared to other specialties (Table 3).

Quality of care was rated very high (88% ranked quality as good, very good, or excellent) for those referred to individual mental health providers, while only half that number gave the same ranking for those referred to mental health carve-out programs. It was felt that the mental health needs of the patient and family were either poor or fair much more often for those referred to mental health carve-out programs compared to those referred to individual mental health providers (Table 3).

A content analysis of comments was also performed (Table 4). Most; interesting were comments in response to the question, "Do you have any suggestions about what should be improved?" Thirty-five of the 99 (35.4%) attending physicians included comments. Qualitative analysis (Strauss and Corbin, 1990) of these comments yielded three general domains:

* organizational/financial constraints to communication between PCPs and MH providers, and how these may be addressed.

* communication issues between PCPs and MH providers.

* concerns about how communication affects patient access to care and quality of care.
TABLE 4 Analysis of Comments

35 of the 99 (35.4%) attending physicians included comments

Organization    Physical location   on site is good
                                    on site is difficult to finance

                Insurance           limitation on benefits for MH
                                    need for open provider networks

                Administrative      phone numbers

                                    directory of MH providers with
                                      areas of interest

                                    PCP not have enough information
                                      about getting patient involved
                                      in mental health care

Communication   no feedback regarding effects on routine illness

                unable to talk with another physician

                standardized forms, 800 numbers are not adequate to
                  communicate scope of MH problem

                need additional training for PCP to understand MH
                  problems, as well as MH provider to understand
                  general medical problems

Patient Care    treatment continuity

                deal only with crisis mode-quick fix

                patients feel abandoned

                difficult to contact MH provider-have to go through
                  intake, social worker

                timeliness-long waits for MH care, sometimes one
                  month to get "prior approval"

                language barriers-i.e. Spanish speaking provider


Discussion

We found that PCPs' perceived ability to treat, but not to recognize mental disorders, were associated with the availability of MH services. We hypothesize that these relationships assist PCPs in developing knowledge and confidence in their ability to manage patients with MH problems. How these relationships are cultivated is a potential topic of investigation. They may be engendered through formal networks (i.e. organizational/financing arrangements that explicitly direct referral and consultation efforts), or through informal networks (i.e. through information brochures on how to reach MH providers). In this exploratory study, PCPs' increased comfort levels in treating mental illness associated with greater access to MH consultation points to the utility of having MH providers available. Future studies should collect more detail about what may influence that relationship, i.e. the frequency of referral, or the nature of consultative and educational contacts.

PCPs felt that the quality of collaboration and referral relationships with individual MH providers was better than those relationships with managed care carve-out programs, especially in the provision of information to MH providers. In general, this finding may point to administrative constraints that many PCPs feel hamper timely access to patient care as well as patient care continuity. Specific examples of these constraints emerged in the comment section, and included concern about difficulties patients may experience in waiting for care; as well as the impersonality those with MH problems encounter when they must talk to intake workers and providers unfamiliar to patients.

Our survey indicated that information exchange between MH providers and PCPs could be improved in both managed care and non-managed care settings, as it is an important aspect of continuity of care. PCPs reported sending less information to MH carve-out providers compared to individual MH providers. However, in both managed care or non-managed care arrangements, approximately 50% of PCPs reported never or seldom receiving information back from MH providers. These responses point out that more study is needed simply of the frequency of communication between PCPs and MH providers. Increasing regular information exchange between PCPs and MH providers may improve the longitudinality of care for those with chronic mental problems, thereby improving quality of care.

Satisfaction with consultation and referral relationships varied between mental health carve-out programs and individual providers. PCPs were significantly less satisfied with their :relationships with carve-out programs. However, when asked to compare collaborative MH relationships to other medical specialists, over half (54.2%) of the respondents were seldom/never satisfied with collaborative relationships with individual providers; and over three-quarters (75.7%) were seldom/never satisfied with carve-out programs. This finding alludes to a general dissatisfaction that PCPs have with MH providers, although more study is needed of the differential relationships the PCP may have with various types of MH providers (i.e. psychiatrists, psychologists, MSW).

Quality of mental health care was perceived to be substantially lower for patients who were referred to MH carve-out programs compared to those referred to individual mental health providers. The Community Tracking Study of Health System Change has recently reported PCP's concerns that their patients do not always have access to high-quality mental health care (Shurchman and St. Peter, 1997). Concerns about the poor quality of care need to be followed up with additional studies that measure individual patient satisfaction and outcomes.

Comments included at the end of the survey brought up many provocative issues. While this type of analysis does not have statistical validity, it is useful in identifying important issues that may be addressed with future work. Comments often took the form of complaints or suggestions, and fell into three general domains: organization, communication, and patient care.

One domain addressed administrative or organizational mechanisms which could help facilitate collaboration. Comments included suggestions for a directory of MH providers, which included specific areas of interest, and open MH provider networks that were not limited by insurance. On-site availability of MH care was seen as very helpful, although difficult to finance. There were several comments that called for more information on how to manage MH problems.

Another domain centered around the content and quality of communication between PCPs and MH providers. Comments in this area addressed the lack of feedback on interactions that psychotropic medications may have on other illnesses, the inability to talk to another physician, the use of standardized forms by carve-outs that do not adequately encompass the scope of the patient's problem, and the differences in training that PCPs and MH providers may require to understand and respect each others' areas of expertise.

A third area addressed patient access to care and treatment continuity. These comments included concerns around patient waiting times, timeliness of care, language barriers, and difficulty in maintaining treatment continuity.

This study, while raising many issues, has several important limitations. Foremost, it is an exploratory survey of generalist physicians affiliated with a single medical school in an urban area. In order to be more generalizable, it would be desirable to replicate this survey with a wider range of physicians in different geographic locations. The survey is also limited as its response rate (41.4%) leaves room for response bias. However, the response rate for the FM physicians was 65.7%, and there were no differences in their responses with those from IM physicians. These data are based upon physician self-report, and it is possible that physician perceptions regarding their patients' access to care will affect their own treatment behaviors, thereby impacting upon quality of care. For instance, PCPs' negative perceptions of MH carve-outs may influence referral rates to these entities. It is desirable to validate these self-reported measures of linkage with other measures. In addition, the self-report measures collected are unable to clearly differentiate how on-site mental health care relates to the classification of "individual providers" and "mental health carve-outs," nor the range of how many different mental health carve-out organizations PCPs worked with. Lastly, findings reported here do not address the question, "In what way do collaborative arrangements affect the process of care, patient outcomes, and costs?" Future studies may seek to correlate kinds of PCP/MH linkage with these types of outcomes/questions.

Conclusion

This pilot study described aspects of PCP/MH provider relationships and raises issues for future research. Through physicians' reports, it also identified potential quality of care problems when PCP/MH linkages were not strongly established. PCPs in this study, in taking seriously their role as care coordinators, desired smoother referrals and significantly improved communication about mutual patient care. Carve-out arrangements were seen as less desirable in both respects. Future research may seek to include more specificity about various facets of collaborative relationships, but even on the basis of this pilot study it appears that PCPs benefit from on-site provision of MH care and that there is a great deal of "linkage" that needs to occur between PCPs and MH providers, starting with simple information exchange about referred patients. Lastly, future research should also address how PCP/MH collaboration and referral relationships may be related to patient outcomes such as recovery and non-remission, service use and costs, and patient satisfaction.

ACKNOWLEDGEMENTS

The authors would like to thank the physicians affiliated with the Departments of Family Medicine and General Internal Medicine of Jefferson Medical College who participated in this survey; as well as Christopher Chambers MD, James Diamond PhD, Junius J. Gonzales MD, Daniel Z. Louis and four anonymous reviewers for their helpful suggestions and encouragement. This survey was funded by the Deanis Overage Research Program at Jefferson Medical College, Philadelphia, Pennsylvania.

ENDNOTES

(1) Individual MH providers were defined as those who practice alone or in group practices, but who are chosen for referral by generalist physicians. Mental health carve-outs were defined as organizations that subcontract with the patient's insurance company for the exclusive provision of mental health care, with referrals typically mandated by the patient's insurance.

(2) Physicians were first asked to estimate an overall percentage of patients with mental health problems within the last year. This question was followed by a list of 15 MH problems commonly encountered in primary care. Physicians were then asked how often they encountered the problem, their confidence in treating it, and their referral and consultation practices for each of the 15 problems.

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Elaine J. Yuen, MBA, Center for Research in Medical Education and Healthcare, Jefferson Medical College, Philadelphia, Pennsylvania.

John L. Gerdes, Ph.D., Department of Psychiatry, Penn State Geisenger Health System, Danville, Pennsylvania.

Shimon Waldfogel, M.D., Department of Psychiatry, Abington Hospital, Philadelphia, Pennsylvania.3
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Author:YUEN, ELAINE J.; GERDES, JOHN L.; WALDFOGEL, SHIMON
Publication:Families, Systems & Health
Date:Sep 22, 1999
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