Relationship Between Type of Insurance and Care During the Early ...

Relationship Between Type of Insurance and Care During the Early Course of Psychosis Jonathan Rabinowitz, D.S.W., Evelyn J. Bromet, Ph.D., Janet Lavelle, M.S.W., Kimberly J. Severance, B.A., Sharon L. Zariello, M.S.W., and Bruce Rosen, M.D.

Objective: Little is known about the relationship between insurance and care in the early course of psychosis. This study explored the insurance status of first-admission psychotic patients and the relationship between type of insurance and care received up to this admission. Method: Data are from the Suffolk County Mental Health Project, an epidemiologic study of first-admission psychosis. Data on insurance status (N=525) were pooled from hospital records, respondents, and significant others. Logistic regression analysis, controlling for key background variables and diagnosis, was used to study the relationship between insurance and care. Results: At first admission, 233 (44%) of the patients had no insurance, 78 (15%) had Medicaid or Medicare, 203 (39%) had private insurance, eight (1.5%) were insured by the Veterans Administration, and the insurance status of three (1.5%) was unknown. Having private insurance increased the likelihood of having received previous mental health treatment (psychotherapy specifically), being admitted voluntarily, being hospitalized in a community hospital rather than a public hospital, and being hospitalized within 3 months of onset of psychosis. Having Medicaid/Medicare increased the likelihood of receiving nonantipsychotic medication before this hospitalization, admission to a community hospital rather than a public hospital, having received previous mental health treatment in general, and voluntary admission. Conclusions: During the early course of psychotic illness, many people lack any type of health insurance, and this is associated with a decreased likelihood of obtaining care before their first hospital admission. (Am J Psychiatry 1998; 155:1392–1397)

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nsurance is an important variable affecting access to health care. Yet little is known about the relationship of insurance to care in the early stages of psychosis. Specifically, little is known about type and adequacy of insurance benefits for patients experiencing their first episode of psychosis and how insurance influences service delivery during the critical early course of illness, Received July 11, 1997; revisions received Nov. 3, 1997, and Feb. 6 and March 17, 1998; accepted April 17, 1998. From the Division of Epidemiology, Department of Psychiatry, State University of New York, Stony Brook. Address reprint requests to Dr. Rabinowitz, School of Social Work, Bar Ilan University, Ramat Gan, Israel. Supported in part by NIMH grants MH-44801 and MH-51359 (Center for the Study of Issues in Public Mental Health) and a Young Investigator Award from the National Alliance for Research on Schizophrenia and Depression (Dr. Rabinowitz). The authors thank Dr. Joseph E. Schwartz for his methodological comments and the project psychiatrists who formulated the psychosis diagnoses, including Drs. Charles Rich, Shmuel Fennig, Marsha Tanenberg-Karant, Gerardo Tolentino, Joan Rubinstein, Noam Eitan, Ranganathan Ram, and Kinga Koreh. They also thank the many mental health professionals in Suffolk County, New York, whose assistance with the study has been indispensable.

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when rapid intervention may improve long-term outcome (1). Using data from the National Comorbidity Survey, the National Advisory Mental Health Council (2) reported that, of individuals with severe mental disorders, 64% had private insurance, 18% were insured by government programs, and 18% had no insurance. This distribution is very similar to that for the U.S. population (64%, 22%, and 14%, respectively). On the other hand, among the approximately 42 National Comorbidity Survey respondents with nonaffective psychosis, only 44% had private insurance, 31% had government insurance, and 25% had no insurance (Kessler, 1997, personal communication). In a consecutive admission sample of 50 patients each from one private and one public psychiatric hospital, Minkin et al. (3) found that although all of the patients in the private hospital had either private insurance or Medicaid/ Medicare, only 36% of those in the public hospital had coverage. Using data from the Epidemiologic Catchment Area (ECA) study, Landerman et al. (4) found that having any insurance coverage for outpatient mental health Am J Psychiatry 155:10, October 1998

RABINOWITZ, BROMET, LAVELLE, ET AL.

care is strongly associated with obtaining care. This relationship was stronger for those patients with a DSMIII diagnosis than those without. Others have found that type of insurance coverage predicted use of services. For example, depressed patients covered by feefor-service plans had more outpatient visits than those insured by prepaid plans (health-maintenance-organization [HMO]-type plans) (5). Similarly, utilization of inpatient services was related to how care was managed (6). Although the few studies conducted have suggested that insurance status has an important association with use of mental health services, a significant limitation has been their reliance on respondents’ reports. Owing to the complexity of insurance, many people are unclear about their insurance coverage. For example, Landerman et al. (4) found that 44% of ECA respondents did not know whether they had mental health insurance coverage. The purpose of this study was to describe the distribution of insurance status, based on multiple sources of information, in a first-admission sample of patients with psychotic disorders and examine the relationship between type of insurance and care received early in the course of the illness. Specifically, we determined whether respondents had health insurance and the type of insurance. Then we examined the relationship between insurance status and having had pharmacotherapy or psychotherapy before first admission, time from onset of psychosis until hospitalization, whether the hospitalization was voluntary or involuntary, and whether the inpatient facility was a public or a community hospital. METHOD Sample and Procedure Data were taken from the Suffolk County Mental Health Project. Details about the design of the Suffolk County study have been presented elsewhere (7). Briefly, the sample was composed of 696 presumed psychotic patients hospitalized in one of the 12 psychiatric facilities in Suffolk County, New York, between September 1989 and December 1995. The facilities included six 20–30-bed community hospital units, a 30-bed university hospital unit, a Veterans Administration (VA) hospital, two private hospitals (added in 1994), an adult state psychiatric center, and a child state psychiatric center. In most hospitals, the chief nurse or chief social worker for the unit identified eligible patients and obtained verbal consent for a project interviewer to contact them. At the academic and adult state facilities, a project interviewer reviewed all admissions (8). The inclusion criteria were age 15–60; resident of Suffolk County; and clinical evidence of psychosis, prescription of neuroleptic medication, or a facility diagnosis indicating psychosis on admission. These broad criteria meant that a small number of patients referred to the study were diagnosed as nonpsychotic by the research team (9). Exclusion criteria were first psychiatric hospitalization more than 6 months before current admission, moderate or severe mental retardation, and non-English-speaking status. The response rate for the initial interview was 72% (N=696).

Informed Written Consent After obtaining written consent for the baseline interview, we obtained written permission from patients to review their medical

Am J Psychiatry 155:10, October 1998

records, talk with the treating clinician, and interview significant others. At the state hospital, according to the institutional requirement, previous written approval was obtained from physicians indicating that patients were competent to provide informed consent.

Diagnosis The Structured Clinical Interview for DSM-III-R (SCID) (10) was administered at baseline and at 6-month follow-up by master’s level mental health professionals who had 3–6 months of training. Interviewers took copious notes, and most interviews were audiotaped. The baseline SCID ratings combined information obtained from the interview, the medical record review, the clinician interview, and the significant other (11). Interrater reliability was routinely checked and, as reported elsewhere (8), was in the acceptable-to-excellent range. Diagnoses of psychosis were based on a consensus of two (baseline) to four (6-month follow-up) psychiatrists after review and discussion of all relevant diagnostic materials (8, 9). In this paper, the 6month follow-up diagnoses were used for 465 patients, and the baseline evaluations were used for 60 patients who did not receive a follow-up assessment. The present analysis is based on 525 respondents with the following DSM-III-R diagnoses: bipolar disorder with psychotic features (N=150), major depressive disorder with psychotic features (N=98), other nonorganic psychoses (N=59), and schizophrenia spectrum psychoses (N=218).

Measures Five demographic variables were analyzed: age, sex, race, marital status, and household socioeconomic status. Although the educational level of patients was known, it was not included in this analysis because many patients were young adults who had not yet reached their terminal point of education. Household socioeconomic status was rated by applying the Hollingshead 7-point occupational scale to the person who contributed the most financially to the household in which the respondent lived at baseline. An additional scale point, number 8, was added for patients whose major source of support was public assistance. In cases where occupational status was unknown (where the primary support came from pension or savings, for example), the rating was made on the basis of the parents’ occupation in the household in which the patient was raised. The higher status was used in the event that two parents had different socioeconomic statuses. Treatment variables included pre-admission treatment history according to clinical interviews and treatment records. These were used to rate type and extent of previous treatment with a modified version of the Strauss-Carpenter Prognostic Scale (12). This included whether the respondent had had previous treatment and the type of this treatment (antipsychotic pharmacotherapy, nonantipsychotic pharmacotherapy, psychotherapy, and other treatment). Substance abuse treatment was not analyzed in this report. Because obtaining psychiatric care often occurs in response to violence or suicide attempts, measures of both were included. Since the current analysis focuses on care obtained during the respondent’s lifetime, lifetime violence and suicide attempt measures were preferred over measures reflecting the behavior only at time of the hospital admission. Suicide attempt was measured by using a dichotomous lifetime variable ascertained as part of the SCID. A three level composite measure of lifetime violence (none, some, and a lot) was created from information on the Strauss-Carpenter Prognostic Scale (12), the interview with the significant other, the hospital discharge record, and the Structured Interview for Schizotypy (13). None was defined as no evidence of violence from any source. Respondents with a lot of violence were those who were rated on the Strauss-Carpenter Prognostic Scale as being frequently violent or who on the Structured Interview for Schizotypy endorsed more than one physical fight as an adult. Respondents not included in the categories of none or a lot were assigned to the category of some violence. Data on insurance status (staff-model HMO, preferred provider, fee for service, Medicaid or Medicare, VA, or no insurance) were assembled from multiple sources (hospital admission and discharge

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TYPE OF INSURANCE AND CARE DURING PSYCHOSIS

TABLE 1. Significant Relationships Between Demographic and Clinical Variables and Insurance Status Among 514 First-Admission Psychotic Patients Private Insurance (N=203)

Patient Variable Race White (N=388) Nonwhiteb (N=126) Sex Female (N=234) Male (N=280) Marital status Never married (N=339) Married (N=96) Divorced-separated (N=68) Type of psychosis Affective (N=244) Nonaffective (N=270) Violence None (N=174) Some (N=203) A lot (N=131)

Socioeconomic status

(N=510)c

a Percentages of row items. b Hispanics (N=37), blacks (N=74), c 1=high; 8=low.

Medicaid/ Medicare (N=78)

No Insurance (N=233)

Analysis χ2 14.9

df 2

p