Utilization Review Drives Treatment Plan Alterations

Approximately half of all patients in a nationally representative sample of psychiatrists were receiving care that was subject to some form of utilization management, according to a report in the June American Journal of Psychiatry. The utilization management was highly associated with treatment changes that may or may not have been in accordance with evidence-based care.

“Our paper objectively highlights that there are substantial differences in psychiatrists' treatment patterns where utilization management, an essential element of managed care, is employed, as compared to when it is not,” lead author Devra C. Mintz, M.D., M.P.H., told Psychiatric News. “Our nationally based findings suggest that practicing psychiatrists provide materially different treatments to patients when they are subject to utilization management of their provision of clinical services.”

Mintz is in private practice in Miami, Fla.

Mintz and colleagues analyzed data on 1,843 patients treated by 615 psychiatrists participating in the American Psychiatric Institute for Research and Education's Practice Research Network (PRN).

Psychiatrists were asked to respond to the questions in the box below as part of a larger survey of the PRN. Responses to the two questions were correlated with responses to other questions.

The researchers found that approximately half (52 percent) of all patients had treatment that was subject to utilization management. Of these patients, 31.5 percent had their treatment plan changed, compared with 15.5 percent of those whose care was not subject to utilization management.

Of the 947 psychiatrists who were subject to utilization management, a total of 355 reported reducing the frequency and/or the number of visits, while 224 said they changed to a different form of treatment— for example, by switching outpatient for inpatient care or providing group rather than individual psychotherapy.

The presence of utilization review or treatment algorithms was not associated with psychiatrists' reported changes in treatment. In contrast, the remaining utilization management techniques—restrictions on medications, financial incentives or penalties to limit referrals, and limiting referrals to selected hospitals or specialist panels—had significant associations with treatment modifications.

For example, the presence of formulary restrictions was associated with a threefold increase in the odds of a physician providing different treatment. Although only 1 percent of the patient group had treatment recommendations restricted by financial incentives or penalties to limit referrals, when present, these techniques were associated with increased odds (3.8) of reducing the frequency or number of visits the psychiatrist would have preferred by a factor of almost 4. And when treatment recommendations were restricted by limiting referrals to selected hospitals or specialist panels, there was a significant increase in the odds (1.8) of the psychiatrist providing treatment that was different from that he or she otherwise would have provided.

After adjustment for differences in patients, settings, and psychiatrist characteristics, the patients whose care was subject to utilization management were 2.6 times more likely to have their treatment changed than the patients who were not so subject.

Psychiatrists in individual practice settings and those with nonsalaried income were more likely to change treatment decisions when subject to utilization management.

“We figured that was probably a function of the fact that [individual practitioners] had less leverage to bargain, because they were less buffered than a psychiatrist working in a large group practice or staff-model HMO,” co-author Benjamin Druss, M.D., the Rosalynn Carter Chair of Mental Health at Emory University School of Medicine. Nonetheless, “it may say something about how they are already practicing.”

“We have had a lot of anecdotal data about the pressures of managed care,” he continued. “This is probably as good a data set as has been available that actually quantifies the effect of utilization management, which has become extremely common. As most clinicians suspect, it does affect behavior in ways that many feel requires them to compromise care.”

But Druss pointed out that it is not known whether the changes in treatment brought about by utilization management conform to guidelines for treatment and evidence-based care. The subject requires further investigation, said the authors.

“Policymakers should carefully analyze whether the differences in treatment associated with the presence of utilization management, a very common technique within managed care, compromise patient outcomes or in any way result in less than optimal care,” said Mintz. “An important step toward ensuring care that is guideline concordant and evidence based would be a close examination of the associated treatment differences and a comparison to nationally accepted standards.”

The study, “Association of Utilization Management and Treatment Plan Modifications Among Practicing U.S. Psychiatrists,” is posted online at<http://ajp.psychiatryonline.org/cgi/content/full/161/6/1103>.▪

Am J Psychiatry 2004 161 1103