Susanne Kraft, Bernd Puschner & Hans Kordy

The relationship between psychotherapy outcome, psychotherapy costs, and general health costs Susanne Kraft, Bernd Puschner & Hans Kordy Center for Psychtherapy Research Stuttgart

Overview • Introduction • Background • Study "TRANS-OP" • Research Questions and Data • Design and Results • Health care costs before psychotherapy: Course and predictors • Health care costs before, during and after psychotherapy: Course and predictors • Summary, open questions, outlook • Discussion

Background • Psychotherapy is highly effective! • Psychotherapy is an established part of the service delivery system • Discovery, innovation, and justification no longer on top of agenda • Today's challenge (period of diffusion): optimizing the service system by intelligent distribution of psychotherapeutic ressources.

Aspects of Psychotherapeutic Services’ Quality • Availability • Effectiveness • Acceptance • Efficiency

Background • high utilization of medical services of persons suffering from mental disorders (hospital stays, physicians’ visits, costs) • "cost-offset": reduction of health care costs following psychotherapy (Mumford et al., 1984; Chiles et al., 1999; Baltensperger & Grawe, 2001) • lack of German studies

Health and Service Systems Management Patients/Insurees Center for Psycho- therapy Research Study TRANS-OP Health Insurance Company ("DKV") Scientific Community Therapists

Sample recruitment: Insuree’s intitial inquiry (“first inquiry”) about psychotherapy at DKV ( Sept. 1998 – Feb. 2001) DKV sends information  Insuree agrees to participate in study CPR sends first questionnaires Transparency and Outcome Orientation in Outpatient Psychotherapy ("TRANS-OP") • Forms of psychotherapy: psychodynamically oriented, behavioral therapy, and psychoanalysis • Study period (clinical data): 2 years • Response rate t1: 714 of 939 (76.04%)

Overview • Introduction • Background • Study "TRANS-OP" • Research Questions and Data • Design and Results • Health care costs prior to psychotherapy: Course and predictors • Health care costs before, during and after psychotherapy: Course and predictors • Summary, open questions, outlook • Discussion

Research Questions • Utilization of medical services prior to outpatient psychotherapy • Amount and course of health care costs during three years before first inquiry? • Amount of health care costs during one year before first inquiry: Relation to clinical and SES variables? • Utilization of medical services before, during and after outpatient psychotherapy • Amount and course? • Change in health care costs (pre-post-comparison): Relation to clinical and SES variables? • Course of health care costs: Effect of session number?

Health care costs • all bills forwarded to the DKV by insuree (excluding medication) during study period (individualized, but no diagnoses) • costs for psychotherapy included Questionnaire data • SES • psychological and physical impairment from patient’s perspective •  SCL-90-R (90 items, 9 scales, General Severity Index) •  GBB (24 Items, Summe) Session number • DKV files Data

Design (1a) Health care costs before first inquiry: Course first inquiry Health care costs 1 2 years 0 -3 -2 - 1

Means x1 = 8765.39 x  1.8 x2= 5808.39 x x x3= 4899.05 Results (1a) Health care costs before first inquiry:Course 3994.46 2433.80 2086.33

first questionnaire Design (1b) Health care costs one year before first inquiry:Relations first inquiry Health care costs N = 608 1 2 years 0 -3 -2 - 1

Results (1b) Health care costs one year before first inquiry:Relation with SES & clinical data R²= .08 Multiple Regression: • psychological impairment (SCL-90-R, GSI) • physical impairment (GBB-24) • age • sex, familiy status, educational and professional degree  = .16  = .21 Analysis of SCL-90-R’s subscales: • SCL-90-R subscale “Somatization” r = .18

Design (2) Health care costs during and after psychotherapy:Course first inquiry Health care costs 1 2 years 0 -3 -2 - 1 • cost data available for relevant period (6 months prior to until 2 years after first inquiry) • first inquiry until June 1999 (at the latest) • termination of psychotherapy 1,5 years after first inquiry (at the latest) N = 121 • filled in and sent back first questionnaire termination of psychotherapy (at the latest) z1 z1 z2 first questionnaire

Results (2a) Health care costs during and after psychotherapy:Course termination of psychotherapy (at the latest) first inquiry x Mean (z1) = 4339.75 x x 2139.46 2337.43 x x 1941.81 Mean (z2) = 2637.12 1302.17 1158.95 40% decrease z1 z2

Results (2b) Change in health care costs:Predictors R² = .54 Multiple Regression: • Health care costs six months before first inquiry (z1) • psychological impairment (SCL-90-R, GSI) • physical impairment (GBB-24) • age • sex, family status, educational and professional degree • problem duration  = .75  = - .16

Results (2c) Change in health care costs: Effect of session number x x x x x x x x x x

Summary • Increase of health care costs prior to first inquiry & subsequent reduction • Clinical & socioeconomic variables show – if so – only minor relationships with health care costs before 1st inquiry (age, physical impairment, somatization) • Best predictor of subsequent reduction: health care costs before first inquiry

Health care costs: complete course termination of therapy (at the latest) first inquiry x x x x x x x x

Open questions, outlook • Effect of psychotherapy costs (outpatient & inpatient)  Detailed analysis of outpatient psychotherapy costs • Selected subsample (small session number)  Further assessment of data • No comparison with typical "DKV-Insuree"  Reference sample  Impact of outcome on cost reduction

Susanne Kraft, Bernd Puschner & Hans Kordy