Wer erhält wie viel Versorgung in der Institutsambulanz und warum?

Zusammenfassung

Anliegen/Methode In einer psychiatrischen Institutsambulanz sollten die Zusammenhänge zwischen individuellen Fallaspekten und Behandlungsaufwand mittels multipler linearer Regression dargestellt werden. Ergebnisse Niedrigerer Behandlungsaufwand war assoziiert mit Wohnen im Heim (β = − 0,319; p < 0,001), höherem Alter (β = − 0,238; p < 0,001), einer bestehenden BGB-Betreuung (β = − 0,165; p = 0,006) und eigenem Erwerbseinkommen (β = − 0,100; p = 0,044). Ein Mehraufwand war mit vorheriger stationärer psychiatrischer Behandlung verbunden (β = 0,181, p = 0,001 resp. β = 0,193; p < 0,001). Schlussfolgerungen Die Ergebnisse eröffnen Fortentwicklungsmöglichkeiten für die Fallvergütung.

Abstract

Aims To elucidate the connections between individual aspects and patients' concerns and the care effort provided in a clinic for the sickest among outpatients. Methods Clients of one health insurer were followed for six months (n = 339) in a „Institutsambulanz” or „PIA”. All treatment activities, which involved roughly 100 000 working minutes, were recorded. Sociodemographic data, the diagnoses, the individual needs and idiosyncracies, symptoms and case history were noted for multivariate analysis. Results The linear regression model with the best fit (n = 251, r² = 0.512, p < 0.001) included six variables. Lower efforts: living in nursing home (β = − 0.319; p < 0.001), higher age (β = − 0.238; p < 0.001), legal incapacity (β = − 0.165, p = 0.006), own work income (β = − 0.100; p = 0.044); higher efforts: inpatient stays prior to study treatment (lifetime: β = 0.181; p = 0.001; number of days in last two years: β = 0.193; p < 0.001). Treatment aims, functional deficits, and diagnoses did not have a significant influence. Conclusions Younger patients who wish for an independent life despite of a grave psychiatric disorder may effectuate higher treatment efforts. Treatments administered to nursing-home inhabitants are far less complex, although these patients are even sicker. The current reimbursement mechanism may serve as a disincentive towards care administration according to individual need.

Schlüsselwörter

Institutsambulanz - Inanspruchnahme - Behandlungsaufwand - Vergütung - § 118 SGB V

Keywords

psychiatric outpatient treatment - utilization - treatment effort - reimbursement

Literatur

• 1 Köster M. Psychiatrische Institutsambulanzen in Baden-Württemberg. Behandlungsauftrag, Arbeitsweise, Evaluation (Diss.). Tübingen; Eberhard-Karls-Universität 2005
• 2 Güssow J. Vergütung integrierter Versorgungsstrukturen im Gesundheitswesen. Wiesbaden; Deutscher Universitäts Verlag 2007: 177-194
• 3 Vincenti A, Keuper F, Brösel G. Cost Reimbursement versus Flat Fee – The Impact on the Efficiency and Effectiveness of Hospitals. In: Keuper F, Neumann F, eds Finance Transformation. Wiesbaden; Gabler 2008: 225-249
• 4 Wittchen H U, Jacobi F. Size and burden of mental disorders in Europe – A critical review and appraisal of 27 studies.  Eur Neuropsychopharm. 2005;  15 (4) 357-376
• 5 Thomas C M, Morris S. Cost of depression among adults in England in 2000.  Br J Psychiat. 2003;  183 (DEC.) 514-519
• 6 Soeteman D I, Roijen L HV, Verheul R. et al . The economic burden of personality disorders in mental health care.  J Clin Psychiatry. 2008;  69 (2) 259-265
• 7 Rupp A, Keith S J. The costs of schizophrenia: Assessing the burden.  Psychiat Clin N Am. 1993;  16 (2) 413-423
• 8 Patel A. The cost of mood disorders.  Psychiatry. 2009;  8 (2) 76-80
• 9 Andlin-Sobocki P, Johsson B, Wittchen H U. et al . Cost of disorders of the brain in Europe.  Eur J Neurol. 2005;  12 (Suppl. 1)
• 10 Knapp M. Costs of schizophrenia.  Br J Psychiat. 1997;  171 (DEC) 509-518
• 11 Insel T R. Assessing the economic costs of serious mental illness.  Am J Psychiatry. 2008;  165 (6) 663-665
• 12 Hoffman D L, Dukes E M, Wittchen H U. Human and economic burden of generalized anxiety disorder.  Depress Anxiety. 2008;  25 (1) 72-90
• 13 Eaton W W, Martins S S, Nestadt G. et al . The burden of mental disorders.  Epidemiol Rev. 2008;  30 (1) 1-14
• 14 DuPont R L, Rice D P, Miller L S. et al . Economic costs of anxiety disorders.  Anxiety. 1996;  2 (4) 167-172
• 15 Alwan N A, Johnstone P, Zolese G. Length of hospitalisation for people with severe mental illness.  Cochrane DB Syst Rev. 2008;  (1)
• 16 Bebbington P E, Brugha T S, Meltzer H. et al . Neurotic disorders and the receipt of psychiatric treatment.  Psychol Med. 2000;  30 (6) 1369-1376
• 17 Ford J D, Trestman R L, Steinberg K. et al . Prospective association of anxiety, depressive, and addictive disorders with high utilization of primary, specialty and emergency medical care.  Soc Sci Med. 2004;  58 (11) 2145-2148
• 18 Glaesmer H, Gunzelmann T, Martin A. et al . The impact of mental disorders on health care utilization and illness behaviour in the elderly.  Psychiat Prax. 2008;  35 (4) 187-193
• 19 Kessler R C, Zhao S, Katz S J. et al . Past-year use of outpatient services for psychiatric problems in the national comorbidity survey.  Am J Psychiatry. 1999;  156 (1) 115-123
• 20 Lorant V, Delige D, Eaton W. et al . Socioeconomic inequalities in depression: A meta-analysis.  Am J Epidemiol. 2003;  157 (2) 98-112
• 21 Murali V, Oyebode F. Poverty, social inequality and mental health.  Adv Psychiatr Treat. 2004;  10 (3) 216-224
• 22 Narrow W E, Regier D A, Norquist G. et al . Mental health service use by Americans with severe mental illnesses.  Soc Psychiatry Psychiatr Epidemiol. 2000;  35 (4) 147-155
• 23 Olfson M, Goldman H H. Psychiatric outpatient practice: Patterns and policies.  Am J Psychiatry. 1992;  149 (11) 1492-1498
• 24 Spengler A. Current problems of outpatient psychiatric-psychotherapeutic care – The role of PIA.  Psychiat Prax. 2008;  35 (7) 361-364
• 25 Melchinger H, Rössler W, Machleidt W. Expenditures in psychiatric treatment – Distributing funds according to need.  Nervenarzt. 2006;  77 (1) 73-80
• 26 Melchinger H. Outpatient psychiatric care: Reversals are urgently required.  Dt Ärzteblatt. 2008;  105 (46) A2457-A2460
• 27 Elgeti H. Daten zur Sozialstruktur und Versorgungsangebot der Landkreise und kreisfreien Städte in Niedersachsen. In: Elegti H, Hrsg Psychiatrie in Niedersachsen – Jahrbuch 2009. 1 ed. Bonn; Psychiatrie-Verlag GmbH 2008: 184-186
• 28 Arbeitskreis OPD .Global Assessment of Functioning. Operationalisierte psychodynamische Diagnostik OPD-2. Das Manual für Diagnostik und Therapieplanung. Bern; Huber 2006: 151
• 29 Guy W. Clinical Global Impressions. ECDEU Assessment Manual for Psychopharmacology. Rockville (MD, USA); National Institute of Mental Health 1976: 218-222
• 30 Hart J T. The inverse care law.  Lancet. 1971;  1 (7696) 405-412
• 31 Wyatt R J, Henter I, Leary M C. et al . An economic evaluation of schizophrenia-1991.  Soc Psychiatry Psychiatr Epidemiol. 1995;  30 (5) 196-205
• 32 Quinlivan R, Hough R, Crowell A. et al . Service utilization and costs of care for severely mentally ill clients in an intensive case management program.  Psychiatr Serv. 1995;  46 (4) 365-371
• 33 Martin A, Leslie D. Psychiatric inpatient, outpatient, and medication utilization and costs among privately insured youths, 1997–2000.  Am J Psychiatry. 2003;  160 (4) 757-764
• 34 Rosenheck R A, Neale M S. Cost-effectiveness of intensive psychiatric community care for high users of inpatient services.  Arch Gen Psychiatry. 1998;  55 (5) 459-466
• 35 V. Sozialgesetzbuch. 2008: 118