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Role of Clinician Specialty and Payment System

Lisa S. Meredith, PhD; Kenneth B. Wells, MD, MPH; Sherrie H. Kaplan, PhD, MPH; Rebecca M. Mazel, MA

Arch Gen Psychiatry. 1996;53(10):905-912.

Abstract
Background
To assess how current policy trends may affect the use of counseling for depression, we examined the variation in the use of counseling and usual clinician counseling style for depression across specialty sectors (psychiatry, psychology, and general medicine) and reimbursement type (fee-for-service or prepaid).

Methods
Three types of observational data from the RAND Medical Outcomes Study: (1) patient-reported demographics, depressive symptoms, clinical status, and perceptions about participation style; (2) clinician reports of counseling during specific patient encounters; and (3) clinician reports of the usual counseling and interpersonal style across patients who were seen in a practice.

Results
While almost all depressed patients who were being treated by mental health specialists received brief counseling for at least 3 minutes, less than half of the depressed patients in the general medical sector received such counseling—even for those patients with a current depressive disorder. Counseling rates were lower under prepaid than fee-for-service care in general medical practices. Psychiatrists relied more on psychodynamic approaches, and psychologists relied more on behavioral therapies relative to each other, but both specialty groups provided longer sessions and used more formal psychotherapeutic techniques (eg, interpretation) than did general medical clinicians. Clinicians who were treating more patients who had prepaid plans reported a lower proclivity for face-to-face counseling, and they spent less time when they were counseling patients compared with clinicians who were treating more patients who had fee-forservice plans; however, these differences were not large.

Conclusion
The use of counseling in the usual care for depression varied by both specialty and payment system, while the usual clinician counseling style differed markedly by specialty, but only slightly by payment system.

Author Affiliations
From the Social Policy Department, RAND, Santa Monica, Calif (Drs Meredith and Wells and Ms Mazel); the Department of Psychiatry and Biobehavioral Sciences, UCLA Neuropsychiatric Institute and Hospital, UCLA School of Medicine, Los Angeles, Calif (Dr Wells); and The Health Institute, New England Medical Center, Boston, Mass (Dr Kaplan).

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