In Touch - March 1998, Volume 6, Number 1

Depression: A Model for Mental Health Management

Women are disproportionately affected by depression, and the condition has a significant economic impact on employers. The fifth symposium in the series "Defining Issues and Monitoring Trends in Women's Health and Managed Care" looked at depression and the place of mental health care in the realm of managed care from logistic, economic, and practical perspectives. Held December 5 in Washington, DC, "Managed Care and Women's Mental Health: A Focus on Depression" featured presentations by the authors of two commissioned papers on the topic, followed by a panel discussion.

Depression is "eminently treatable" and should serve as "a model for managing mental health and other chronic illnesses," according to Mary Jane England, MD. England, president of the Washington Business Group on Health, a nonprofit health policy and research organization, began the program with an overview of the topic. Of the costs of depression to employers, she said, treatment accounts for only 28 percent, while 55 percent results from reduced productivity and absenteeism and 17 percent from premature death.

From 97 million to 150 million employees have access to behavioral health care--a term that describes both mental health care and substance abuse services--through some form of carve-out program. England cited a study showing that a high number of days off the job because of disability is directly related to poor quality mental health benefits. If employers improve the quality of behavioral health care offered to employees, England said, "costs go down, and more people get care." Ultimately, employers save money when employees receive effective treatment.

Economist Richard G. Frank, PhD, of Harvard University's Department of Health Care Policy, discussed his paper, "Carve-Outs, Women, and the Treatment of Depression," which he authored with Haiden Huskamp and Vanessa Azzone.
If a health care plan provides good mental health care, Frank reasoned, it attracts people who use those services, who are, in turn, more expensive to treat than the average patient, usually because of the ongoing nature of treatment. Therefore, managed care organizations compete to ensure that their mental health services are "not the best show in town," he said. When the employer (payer) selects the best mental health service provider available and offers that as a separate benefit to employees, the managed care (or other health care) organizations who compete for those employees' enrollment do so without having to take into consideration the costs of one of the most expensive types of care. Such a situation eliminates the disincentive to provide good quality mental health care, Frank concluded.

Frank recognized that carve-outs in either situation create problems with continuity of care and patient confidentiality. In later discussion, Frank also pointed out that few people have access to good quality mental health services at all and emphasized that the overall provision of such services requires much improvement.

Monica E. Oss authored "Managed Care Approaches and Models for the Treatment and Management of Depression: Specific Issues for Women" with Henry Yennie, Sally A. Johnston, and Leo McLaughlin. Oss is the president of Open Minds, a private corporation for marketing and research in mental health and chemical dependency.

Oss focused on the need for treatment guidelines aimed specifically at women with depression. She and her colleagues surveyed numerous health insurance providers and found that none had gender-specific treatment programs for depression. "We can't take managed care organizations to task for their lack of gender discretion," Oss said. "The two most commonly cited guidelines, those of the American Psychiatric Association and the Agency for Health Care Policy and Research, make references to differences, but neither has specific guidelines or recommendations by gender."

The panel discussion began with the comments of Jim Harburger, MD, chair of the Mental Health Executive Committee of Harvard Pilgrim Health Care.
Harburger described himself as "the voice of integrated care," saying his organization has offered unlimited coverage for mental health and substance abuse services since 1971. He admitted such coverage is costly. However, research suggests that those with complex medical problems concurrent with depression have higher costs of care, different recovery rates, and higher death rates if the depression is not addressed, he noted.
Clarissa Marques, PhD, executive vice president and chief clinical officer of Green Spring Health Services, offered "an insider's perspective--what we know about women's health care behavior and how it impacts their ability to get treatment," she said. She gave detailed information from Green Spring's extensive experience with women seeking mental health services for themselves and for their family members.

Mary Ciotti, MD, FACOG, of the Department of Obstetrics, Gynecology, and Reproductive Biology at Michigan State University, said both papers brought to light the lack of information available in the field regarding women and mental health care. According to her own research findings, Ciotti said, most primary care physicians consider detection of depression their responsibility (although there is no consensus regarding the responsibility for treatment), and they are open to learning more about screening instruments.
Clinical psychologist and former Capitol Hill staffer Margy Heldring, PhD, complimented Frank and Oss for "putting these issues in the context of health and social systems." Heldring, a senior associate in health policy at the James McGregor Burns Academy of Leadership at the University of Maryland, continued, "One of the great rationales for looking at these issues is, of course, the economic and personal effects, but also the impact that women's good health has on those around them."

Questions to the panel and the presenters from the audience addressed progress toward new guidelines on depression treatment specifically for women, why more women receive medical treatment with SSRIs (selective serotonin reuptake inhibitors, such as Prozac) than do men, the future of long-term psychotherapy in light of increasingly effective medications, and the implications for coordination of care if mental health services continue to be separated from other health services.

Audiocassettes of the series are available; for more information, call the Jacobs Institute at 202-863-4990.

(L-R) Presenters Mary Jane England, MD; Richard G. Frank, PhD; and Monica E. Oss at the December managed care symposium. PHOTO: LOUISE RANSOM

While many of the speakers at the Jacobs Institute's sixth managed care symposium detailed the flaws of Medicaid managed care programs, some also focused on what's right--small, targeted programs for low-income people that have succeeded in achieving better health outcomes. Two speakers summarized their research into the effects of Medicaid managed care programs on women's health at the symposium, held February 19 at Washington, DC's Willard Hotel. Four panelists then offered their own perspectives.

Amy Bernstein, ScD, senior research manager at the Alpha Center in Washington, DC, a nonprofit health policy research organization, concluded from her investigation that the variations of what is loosely called managed care are so diverse as to be nearly impossible to categorize and track. For her paper, "What Factors Affect Women's Experience with Medicaid Managed Care," she perused the literature, identifying factors such as federal and state regulations, local market conditions, provider characteristics, and population characteristics. All of these come into play where women's health issues, the managed care industry, and Medicaid intersect.

"It's hard to sort out one variable at a time," Bernstein said, but with more research, "we can identify some areas where there are policy solutions that could affect the way Medicaid is provided." First, much current research focuses on pregnancy outcomes, and more information is needed on care for nonpregnant women. Other areas to investigate are access to specialty care the effects of disenrollment and avoiding the patient dissatisfaction that results from major substantial changes in the provision of health care services.

Alina Salganicoff, PhD, of the Kaiser Commission on Medicaid and the Uninsured presented preliminary findings from a 1995-96 Kaiser Family Foundation/Commonwealth Fund survey of 5,000 low-income women in Minnesota, Oregon, Tennessee, Florida, and Texas. The sample included women in Medicaid managed care programs and fee-for-service programs, as well as those who were privately insured.

In summary, Salganicoff found that, compared with private-sector health care, Medicaid provides coverage to a more vulnerable group of women; early experience of Medicaid managed care has not improved patients' access to and satisfaction with care; women in Medicaid managed care experience poorer access, lower satisfaction, and greater problems; rapid growth in Medicaid managed care highlights the need to proceed with caution; and all low-income women face barriers to health care, but the effects are particularly injurious to uninsured women.

Both Bernstein's and Salganicoff's papers will be published in Women's Health Issues, the journal of the Jacobs Institute for Women's Health.

Panelist Sara Rosenbaum, JD, director of the Center for Health Policy Research at George Washington University Medical Center noted, "These problems are intensifying.

"The booming economy is causing a drop in Medicaid enrollment, which is causing problems for plans that have calculated costs based on enrollees," she noted. Those who have dropped out of Medicaid because they now have jobs may still be uninsured. Among the uninsured, those who need health care will seek it only when they are very sick. "Not only will there be fewer people in the program," concluded Rosenbaum, " but those who are in it will be sicker."

Panelist Mary Dewane, chief executive officer of CalOPTIMA, an independent health care authority in Orange County, California, described the progressive, locally based program. CalOPTIMA serves poor people in a county that has no public hospitals or clinics and has traditionally relied on the hospital at the University of California--Irvine for health care for the poor. It has 210,000 members at present, 45,000 fewer than it did just two years ago.

Dewane outlined some of CalOPTIMA's successes with targeted programs on a local scale. "Unlike fee-for-service plans," she noted, "we can redirect funds away from fee-for-service efforts to create programs." The plan's health education programs include parenting classes and preventive health and fitness classes, as well as education about breast cancer, heart disease, domestic violence, and substance abuse. The successful parintal care support services program has improved birth outcomes while also using the opportunity "to engage women in their own health care," said Dewane.

Panelist Sylvia Drew Ivie, JD, a past member of the Institute's Board of Governors and executive director of T.H.E. ("To Help Everyone") Clinic, a model safety net provider in southwest Los Angeles, points out that clinics like hers care for the 45 billion people in this country who are not in managed care programs. Ivie notes T.H.E. Clinic is the only one of its kind in an area with 260,000 uninsured people. T.H.E. Clinic recently became part of the Medicaid managed care system in the area.

"I used to worry about patients; now I worry about bosses and audits," says Ivie. She hopes that a new "third generation" of health care providers will look closely at safety net providers and the successful programs they have developed. For example, T.H.E. Clinic's prenatal care program boasts that the number of low-birth-weight babies born to African-American women in the program is below both the state and national averages.

"We have to measure what's working and keep doing what is good, whether under managed care or for the uninsured," said Ivie.

Panelist Fay Molly Biernat, MD, medical consultant for the State of New Jersey's Medicaid program, noted that New Jersey was the first state to pass laws against "drive-through deliveries," mandating specific minimum lengths of hospital stays for women who had just given birth. Of the nearly 600,000 people eligible for Medicaid in the state, about 63 percent are enrolled. The state programs provide extensive preventive, diagnostic, rehabilitative, and therapeutic services through both HMO and fee-for-service structures. Biernat points out that the state requires providers to meet high health standards and that performance is being evaluated, but no solid data has yet been produced.

Questions from the audience concerned the future for safety net providers, how health care providers can assess their own data, coordination of Medicaid care with Medicare, and the problems of creating new, targeted health programs with decreased funding.

The managed care symposium series is supported by The Commonwealth Fund, the Henry J. Kaiser Family Foundation, Eli Lilly and Company, and Wyeth-Ayerst Laboratories. For audiocassettes of the symposium, call the Jacobs Institute at 202-863-4990.

(L-R) Fay Molly Biernat, MD; Sylvia Drew Ivie, JD; Amy Bernstein, ScD; Alina Salganicoff, PhD; Mary Dewane; and moderator Carol Weisman, PhD, at the Jacobs Institute's sixth managed care symposium in Washington. PHOTO: LOUISE RANSOM

March 19-22, Advance Curriculum on Women's Health, First International Conference, Miami, FL. Contact the American Medical Women's Association by e-mailing [email protected] or visit the web site at http://www.amwa-doc.org.

March 26, Jacobs Institute Breakfast Seminar, Cancer, Genetics and Women's Health with Karen Johnson, MS, Washington, DC, J.W. Marriott, 8-10 am. Call the Jacobs Institute at 202-863-4990.

March 26-27, Promoting Quality and Access in Women's Health Services, San Diego, CA. Call IBC USA Conferences, Inc., at 508-481-6400 or e-mail [email protected]

April 30, Second Annual Jacobs Institute Excellence in Women's Health Awards Luncheon in Washington, DC. See page 3.

May 2-6, Advocacy Training Conference, Washington, DC (sponsored by the National Breast Cancer Coalition Fund). Call McVeigh Associates at 1-800-726-5655, ext. 302.

May 28, Managed Care and Chronic Disease (sponsored by the Jacobs Institute of Women's Health), Washington, DC. Call Julie Gonen at 202-863-4994 for more information.

June 25-27, National Assembly on School-Based Health Care: Communities Creating Access to Care, Los Angeles, CA. Call 1-888-286-8727.

TBA, Managed Care Quality Measurement (sponsored by the Jacobs Institute of Women's Health), Washington, DC. Call Julie Gonen at 202-863-4994 for more information.

Women's Health Issues, the official journal of the Jacobs Institute of Women's Health, is accepting manuscripts for the annual Leadership Award, a manuscript prize award of $1,000, for the best submission on "Health Care for Older Women: The Role of the Ob-Gyn in Providing Health Care for Women Over Age 55." The deadline for submissions is March 31, 1998. For more information, call Elizabeth Markle at 202-863-4990.

Strategies for Adolescent Pregnancy Prevention, by the American College of Obstetricians and Gynecologists, discusses effective models and programs, notes current literature, and lists other resources on the topic. Limited copies are available free of charge; call ACOG's Lisa Smith at 202-863-2497.

Women's Health Legislation in the 105th Congress outlines 30 legislative proposals on women's health currently pending in Congress and provides an overview of congressional action on women's health since 1990. Free copies are available from Women's Policy, Inc., by calling 202-554-2346, or visit Women's Policy, Inc.'s web site at www.womenconnect.com/WPI/index.htm for a look at the introduction and table of contents.

Cancer and Genetics: Answering Your Patients' Questions, a 150-page manual from the American Cancer Society and PRR, Inc., gives an overview of current questions in genetic testing to help providers answer patients' questions about inherited cancer syndromes. For a free copy, call the American Cancer Society, 1-800-227-2345.

Genetic Testing for Breast Cancer Risk: It's Your Choice, a video, companion brochure, and fact sheet created by the National Action Plan on Breast Cancer, is available to answer women's questions about genetic testing for breast and ovarian cancer. ABC News Correspondent Cokie Roberts narrates the video. Video kits are $6 each; up to 25 copies of the brochure only are free. Contact Cathy Chapman at R.O.W. Sciences, Inc., 301-468-6555, ext. 2140, or http://www.napbc.org.

Your Guide to Women's Health, 3rd ed., an FDA Consumer special report, includes articles on heart disease, AIDS, infertility, birth defects, and many other topics. Cost is $9.50. For a single copy, call the FDA Office of Consumer Affairs at 1-800-532-4440; for multiple copies, write to the Government Printing Office's Superintendent of Documents, PO Box 371954, Pittsburgh, PA 15250-7954.

Join the Jacobs Institute of Women's Health as it honors one person who pioneered the way for other women in the field of obstetrics and gynecology and two who have helped improve health care for millions of Americans through their national efforts. The second annual Excellence in Women's Health Awards luncheon takes place from noon to 2 PM Thursday, April 30, 1998, at the National Museum of Women in the Arts in Washington, DC.

Actress Lynda Carter will host the gathering as the Institute presents its first-ever Warren H. Pearse Lifetime Achievement Award to Luella Klein, MD, FACOG. Klein was the first woman president of the American College of Obstetricians and Gynecologists (ACOG) and is currently ACOG's director of Women's Health Issues. She is also the Charles Howard Candler Professor of Obstetrics and Gynecology at the Emory University School of Medicine. The award will be presented by its namesake, Warren H. Pearse, MD. Pearse served as ACOG's executive director for fifteen years and is currently the editor of Women's Health Issues, a peer-reviewed bimonthly journal published by the Jacobs Institute.

The Honorable James M. Jeffords, chair of the Senate Labor and Human Resources Committee, and David Satcher, MD, PhD, United States Surgeon General and former director of the Centers for Disease Control and Prevention (invited), will receive the Institute's 1998 Excellence in Women's Health Awards. Senator Jeffords has worked hard in support of legislation to ensure quality health care for America's children and working families. Dr. Satcher's tenure at the CDC brought a new emphasis on the role of prevention in overall health care, including expansion of the Centers' breast and cervical cancer screening programs to all 50 states.

The $5,000 Corporate Partners ticket offers two tables for ten, prominent listing in the event invitation and program, and recognition at the event. The $2,500 Corporate Supporter ticket offers one table for ten, listing in the event invitation and event program, and recognition at the event. At $250, "Friends of Warren" will receive two tickets to the event, listing in the event invitation and program, and recognition at the event. Individual tickets are $100. To purchase tickets to the luncheon, call 202-863-4990.

William G. Swartz has been named the 1998 Jacobs Institute of Women's Health--Ortho-McNeil Pharmaceutical Scholar in Women's Health. Swartz was chosen from a pool of 75 applicants for his proposal to study the relationship of occupational demands to birth outcomes.

Swartz will use the $30,000, 12-month grant to assess the work-related physical demands on active-duty women of childbearing age in the US Army from 1980-1994. The data comes from the Total Army Injury and Health Outcomes Database, which contains demographic, occupational, hospitalization, and health risk information on more than one million women. The uniformity of occupational tasks within the military will allow Swartz to evaluate the effects of certain physical tasks on the risk of early pregnancy loss, preterm birth, and low birth weight.

The impact of work on birth outcome has been controversial, with prior research focusing mainly on women's exposure to chemicals on the job. "Working during pregnancy, once relatively uncommon, is now the norm," says Martha Romans, executive director of the Jacobs Institute. "Yet, there is no definitive information about the impact of different types of work on pregnancy complications. The Total Army Injury and Health Outcomes Database is an especially rich one, and Mr. Swartz's project will no doubt be a major contribution to our knowledge in this area," Romans points out.

Swartz is a research associate at the Norris Cotton Cancer Center and the Department of Community and Family Medicine at the Dartmouth Medical School. A member of the Society for Epidemiological Research, he is completing a doctoral degree in epidemiology at the University of Massachusetts.

Finding ways to improve the delivery of health care services to women is the focus of the annual Jacobs Institute--Ortho-McNeil Pharmaceutical Scholar award. Research that considers the changing health care environment, the unmet need for primary and preventive health services, the historic lack of research on women's health, and the importance of social, cultural, legal, economic, and behavioral factors influencing the financing and delivery of health care to women is eligible. The application deadline for the 1999 award is October 15, 1998. For more information, call the Jacobs Institute at 202-863-4990 or visit the home page at jiwh.org.

William G. Swartz (center) accepted the 1998 Ortho-McNeill Pharmaceutical Scholar award at a press conference in Washington, DC. On hand for the event were (L-R) Warren H. Pearse, MD, editor, Women's Health Issues; Constance J. Bohon, MD, Jacobs Institute President; Col. Maggie Knapp, U.S. Department of Defense; and Ernest Thompson of Ortho-McNeil Pharmaceutical. PHOTO: MAURICE G. FITZGERALD

State Profiles in Women's Health, edited by Jacqueline Horton, ScD, and made possible with grants from Wyeth-Ayerst and the Henry J. Kaiser Family Foundation, is the Jacobs Institute's latest ground-breaking publication. State Profiles will examine the health status of women on a state-by-state basis. Look for it this summer! For more information or to pre-order, call the Jacobs Institute at 202-863-4990.

The Jacobs Institute of Women's Health is pleased to welcome two new members to the staff:

Shannon R. Mouton joined the Institute in December as the director of Development and

Marketing. Her responsibilities include fundraising, media relations, and communications.

Monica Barbour, administrative assistant, is our newest staff member. She was formerly part of ACOG's membership staff. Monica is responsible for maintaining membership records, keeping up with journal correspondence, and fulfilling publication orders.

Julianna S. Gonen, PhD, research associate, was recently named to the Whitman Walker Clinic's Community Advisory Committee. She also serves as an adjunct professor for American University's Political Science department.

Elizabeth S. Markle, MPH, program assistant, spoke at the Adolescent Employment Readiness Center during Career Awareness Day at the Children's National Medical Center Saturday, March 7. She was part of a panel for young adults with chronic illness and disabilities that discussed working and achieving goals. In December, she became a Certified Health Education Specialist.

Welcome to the following new members of the Jacobs Institute, who joined between December 1997 and February 1998. To become a member, complete the order form below. For more information on membership, call the Jacobs Institute at 202-863-4990.

American Association of Retired Persons, Diversity Programming/Women's Initiative

1997 donor ACOG District IX was mistakenly omitted from the 1997 Annual Report. We apologize for the error.