This lecture will review the key elements of population-based care that our research team has used to improve the care of major depressive disorder in a large HMO population and apply these principles to patients with bipolar disorder. These key elements include: identifying a targeted population; redesigning roles within a system of care to ensure more frequent followup and monitoring of outcomes; information systems that can track visits, medication refills, and laboratory tests, and which can provide reminders to clinicians and patients when these are not done in a timely manner; methods to educate and activate patients to become collaborative partners in their own care; careful monitoring of outcomes and facilitation of referral to specialists for patients with persistent symptoms. Treatments are based on evidence based guidelines and regular communication with clinical experts.

We will present data from a large Seattle based HMO that suggest that many of the above principles could be used to improve outcomes in this HMO population. Data from this HMO has shown that about 83% of patients with bipolar illness received medication treatment over a one-year period; approximately half of patients receiving mood stabilizer treatment had at least one seven month period without a recorded blood level; and at least 25% did not make a visit during each of the three intervals examined (followup visit at least every 90 days, followup visit within 90 days of discontinuing a mood stabilizer, and visit to a mental health provider within 14 days of an inpatient psychiatric discharge).

Unutzer J, Simon G, Pabiniak C, Bond K, Katon W: Patterns of care for adults within a large staff model HMO. In review.

Clinician Incentives for Improving Quality

Howard Goldman, M.D., Ph.D.
Bibliography

Slide Presentation

Historically, professionalism has been the prime clinician incentive for improving quality. Realists note that clinical care is a business as well as a profession, and as such, financial incentives are also an important influence on quality. If the quality of clinical care declines, so might demand for care. Of course that implies that patients can recognize quality care and have some degree of choice. As professional clinical care has come under increased pressure to contain costs, financial incentives have become even more significant determinants of quality of care.

Incentives are the opposite of constraints. Providing clinical incentives for quality often means removing constraints. Recent pressures to reduce treatment costs under managed care threaten quality of care by creating an incentive to under-treat patients. This is particularly problematic for a severe and chronic condition, such as bipolar disorder. On the other hand, managed care utilization techniques offer the potential for targeting cost-effective treatments efficiently and avoiding quality of care problems due to over-treatment. Management of patients with bipolar disease is complex, and access to quality services has been limited to some extent by barriers in financing coverage policies. Quality care for patients with bipolar disorder requires financing for both acute and long-term services, which is not often available from a single health care payor or provider.

This presentation explores clinician incentives for quality under fee-for-service and various managed care arrangements.

VA Cooperative Study #430: "Reducing the Efficacy-Effectiveness Gap in Bipolar Disorder"

Mark S. Bauer, M.D.
Bibliography

Slide Presentation

Introduction: The VA Cooperative Study has funded a 12-site randomized controlled trial of an easy-access program for bipolar disorder from 1997-2003. This study proposes that increased access and provider and patient education will reduce the "efficacy-effectiveness gap" for bipolar disorder. We specifically hypothesize that compared to usual VA care (UVAC) the easy-access Bipolar Disorders Program (BDP), will improve clinical, functional, and economic outcome.

Methods: Patients who are admitted to a acute psychiatric ward with a primary or co-primary admission diagnosis of bipolar disorder type I or II are screened for the study. One hundred and ninety-one patients are being randomized to each of the two treatment groups (BDP and UVAC). All enrolled patients are followed up for three years.

Results: All 12 sites have been trained to criterion and are fully functioning. As of January 1, 1999, 1323 patients have been screened and 142 patients have been randomized (73 BDP and 69 UVAC), which is 103% of the current randomization goal.

Discussion: This study will have impact on both the private and the government healthcare sectors. It is designed to evaluate the basic principle that augmenting ambulatory access for major mental illness will improve outcome and reduce overall treatment costs. If results are positive, this study will provide reason to reconsider the prevailing trend toward limitation of ambulatory service that is characteristic of many managed care systems today. Further, the study will provide specific direction with regard to how to structure such ambulatory services.

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