Treating depression in staff-model versus network-model managed care organizations Authors
Cite this article as: Meredith, L.S., Rubenstein, L.V., Rost, K. et al. J GEN INTERN MED (1999) 14: 39. doi:10.1046/j.1525-1497.1999.00279.x Abstract OBJECTIVE: To compare primary care providers’ depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations. DESIGN: Survey of primary care providers’ depression-related practices in 1996. SETTING AND PARTICIPANTS: We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care. MEASUREMENTS AND MAIN RESULTS: We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment. CONCLUSIONS: Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs. Key words depression knowledge attitudes practice primary care managed care
Earlier versions of this paper were presented at the Eleventh International Conference on Mental Health Problems in the General Health Care Sector, Washington D.C., September 1997, and the Sixteenth Annual VA Health Services Research and Development Meetings, Washington, D.C., February 1998.
This research was supported by grants from the National Institute of Mental Health (U01-MH54443, U01-MH54444, U01-MH50732, and P01-MH54623) and the Agency for Health Care Policy and Research (R01-HS08349).
Regier DA, Narrow WE, Rae DS, Manderschied RW, Locke BZ, Goodwin FK. The de facto U.S. mental and addictive disorder service system: epidemiologic catchment area prospective one-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50:85–94.
Kessler RC, McGonagel KA, Shanzang Z, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Study. Arch Gen Psychiatry. 1994;51:8–19.
Schreter RK. Ten trends in managed care and their impact on the biopsychosocial model. Hosp Commun Psychiatry. 1993;44:325–7.
Tunis SR, Hayward RSA, Wilson MC, et al. Internists’ attitudes about clinical practice guidelines. Ann Intern Med. 1994;120:956–63.
Martin DP, Diehr P, Price KF, Richardson WC. Effect of a gatekeeper plan on health services use and charges: a randomized trial. Am J Public Health. 1989;79:1628–32.
Kleinman LC, Boyd EA, Heritage JC. Adherence to prescribed explicit criteria during utilization review: an analysis of communications between attending and reviewing physicians. JAMA. 1997;278:497–501.
Kerr EA, Mittman ES, Hays RD, Siu AL, Leake B, Brook RH. Managed care and capitation in California: how do physicians at financial risk control their own utilization? Ann Intern Med. 1995;123:500–4.
Goold SD, Hofer T, Zimmerman M, Hayward RA. Measuring physician attitudes toward cost, uncertainty, malpractice, and utilization review. J Gen Intern Med. 1994;333:544–9.
Emmons DW, Chawla AJ. Physician perceptions of the intrusiveness of utilization review. Stud Socioecon Environ Med. 1991;3–8.
Kerr EA, Mittman ES, Hays RD, Leake B, Brook RH. Quality assurance in capitated physician groups: where is the emphasis? JAMA. 1996;276:1236–9.
Landon BE, Wilson IB, Cleary PD. A conceptual model of the effects of health care organizations on the quality of medical care. JAMA. 1998;279:1377–82.
Wholey DR, Burns LR. Organizational transitions: form changes by health maintenance organizations. Res Sociol Organi. 1993;1:257–93.
Wholey DR, Feldman R, Christianson JB, Engberg J. Scale and scope economies among health maintenance organizations. J Health Econ. 1996;15:657–84.
Gold MR, Hurley R, Lake T, Enso T, Berenson R. A national survey of the arrangements managed-care plans make with physicians. N Engl J Med. 1995;333:1678–83.
Harris JS. Why doctors do what they do: determinants of physician behavior. J Occup Med. 1990;32:1207–20.
Gold M, Hurley R. The role of managed care “products” in managed care plans. Inquiry. 1997;34:29–37.
Wells KB, Hosek SD, Marquis SM. Effects of preferred provider options on use of outpatient mental health services by three employee groups. Med Care. 1992;30:412–27.
Felt-Lisk S. How HMOs structure primary care delivery. Managed Care Q. 1996;4:96–105.
Burns LR, Wholey DR. Differences in access and quality of care across HMO types. Health Serv Mgmt Res. 1991;4:32–45.
Shenkin BN. The independent practice association in theory and practice: lessons from experience. JAMA. 1995;273:1937–44.
Shenkin BN. Models of managed care: the potential power of the IPA. Managed Care Q. 1996;4:68–74.
Rogers WH, Wells KB, Meredith LS, Sturm R, Burnam MA. Outcomes for adult depressed outpatients under prepaid and fee-forservice financing. Arch Gen Psychiatry. 1993;50:517–25.
Retchin SM, Brown B. The quality of ambulatory care in medicare health maintenance organizations. Am J Public Health. 1990;80:411–5.
Johnstone PM. A glimpse of an IPA as a living system. Behav Sci. 1995;40:304–13.
Depression Guideline Panel. Agency for Health Care Policy and Research Clinical Practice Guidelines: Depression in Primary Care. Rockville, Md: US Department of Health and Human Services; 1993.
Ashworth CD, Williamson P, Montano D. A scale to measure physician beliefs about psychosocial aspects of patient care. Soc Sci Med. 1984;19:1235–8.
Main DS, Lutz LL, Barrett JE, Matthew J, Miller RS. The role of primary care clinician attitudes, beliefs, and training in the diagnosis and treatment of depression: a report from the Ambulatory Sentinel Practice Network Inc. Arch Fam Med. 1993;2:1061–6.
Meredith LS, Wells KB, Kaplan S, Mazel RM. Counseling typically provided for depression: role of clinician specialty and payment system. Arch Gen Psychiatry. 1996;53:905–12.
Rost K, Humphrey J, Kelleher K. Physician management preferences and barriers to care for rural patients with depression. Arch Fam Med. 1994;3:409–14.
Huber PJ. The behavior of maximum likelihood estimates under nonstandard conditions. In: Fifth Berkeley Symposium on Mathematical Statistics and Probability. Berkeley, Calif: University of California; 1967;1:221–33.
Neuhous JM. Statistical methods for longitudinal and clustered designs with binary responses. In: Statistical Methods in Medical Research. 1992;1:249–73.
Shao W-A, Williams JW, Lee S, Badgett RG, Aaronson B, Cornell JE. Knowledge and attitudes about depression among non-generalists and generalists. J Fam Pract. 1997;44:161–8.
Meredith LS, Wells KB, Camp P. Clinician specialty and treatment style for depressed outpatients in primary care with and without medical comorbidities. Arch Fam Med. 1994;3:1065–72.
Veloski J, Barzansky B, Nash DB, Bastacky S, Stevens DP. Medical student education in managed care settings. JAMA. 1996;276:667–71.
Eisenberg JM, Williams SV. Cost containment and changing physicians’ practice behavior: can the fox learn to guard the chicken coop? JAMA. 1981;246:2195–201.
Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med. 1993;329:1271–4.
PubMed CrossRef Copyright information
© Society of General Internal Medicine 1999