title: Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms.
abstract: OBJECTIVE
  To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Offices of 261 primary physicians in private practice in Seattle.
  
  
  METHODS
  Patients (N = 17,187) were screened in waiting rooms, enrolling 1,336 adults with depressive symptoms. Patients (n = 942) completed follow-up surveys at 1, 3, and 6 months.
  
  
  RESULTS
  For each patient, the intensity of managed care was measured by the managedness of the patient's health plan, plan benefit indexes, presence or absence of a mental health carve-out, intensity of managed care in the patient's primary care office, physician financial incentives, and whether the physician read or used depression guidelines. Access measures were referral and actually seeing a mental health specialist. Outcomes were the Symptom Checklist for Depression, restricted activity days, and patient rating of care from primary physician. Approximately 23% of patients were referred to mental health specialists, and 38% saw a mental health specialist with or without referral. Managed care generally was not associated with a reduced likelihood of referral or seeing a mental health specialist. Patients in more-managed plans were less likely to be referred to a psychiatrist. Among low-income patients, a physician financial withhold for referral was associated with fewer mental health referrals. A physician productivity bonus was associated with greater access to mental health specialists. Depressive symptom and restricted activity day outcomes in more-managed health plans and offices were similar to or better than less-managed settings. Patients in more-managed offices had lower ratings of care from their primary physicians.
  
  
  CONCLUSIONS
  The intensity of managed care was generally not associated with access to mental health specialists. The small number of managed care strategies associated with reduced access were offset by other strategies associated with increased access. Consequently, no adverse health outcomes were detected, but lower patient ratings of care provided by their primary physicians were found.
authors.affiliation: Center for Cost and Outcomes Research, Department of Health Services, University of Washington, Seattle, Wash 98195-7660, USA. grem@u.washington.edu
authors.forename: David E
authors.initials: DE
authors.lastname: Grembowski
authors.forename: Diane
authors.initials: D
authors.lastname: Martin
authors.forename: Donald L
authors.initials: DL
authors.lastname: Patrick
authors.forename: Paula
authors.initials: P
authors.lastname: Diehr
authors.forename: Wayne
authors.initials: W
authors.lastname: Katon
authors.forename: Barbara
authors.initials: B
authors.lastname: Williams
authors.forename: Ruth
authors.initials: R
authors.lastname: Engelberg
authors.forename: Louise
authors.initials: L
authors.lastname: Novak
authors.forename: Deborah
authors.initials: D
authors.lastname: Dickstein
authors.forename: Richard
authors.initials: R
authors.lastname: Deyo
authors.forename: Harold I
authors.initials: HI
authors.lastname: Goldberg
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003866:Depressive Disorder / Q000175:diagnosis / Q000628:therapy*; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D008329:Managed Care Programs / Q000592:standards* / Q000639:trends; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D011446:Prospective Studies; D012017:Referral and Consultation / Q000592:standards* / Q000639:trends; D014861:Washington