Individual versus Family Psychotherapy in Managed Care: Comparing the Costs of Treatment by the Mental Health Professions
Crane, D. Russell, Payne, Scott H., Journal of Marital and Family Therapy
In an effort to understand how psychotherapy is practiced in the "real world," outpatient claims data were examined to determine the cost of individual and family therapy provided by marital and family therapists, master's nurses, master's social workers, medical doctors, psychologists, or professional counselors. Claims for 490,000 unique persons over 4 years were obtained from CIGNA. Family therapy proved to be substantially more cost-effective than individual or "mixed" psychotherapy. Physicians provided care in the fewest sessions, marital and family therapists had the highest success (86.6%) and lowest recidivism rates (13.4%), and professional counselors were the least costly. Outcomes were overwhelmingly successful, with 85% of patients requiring only one episode of care.
There is scant research comparing the mental health disciplines, either by cost or treatment modality. No large-scale studies could be found that distinguished among the mental health professions, and those that exist fail to take a comprehensive look at payment and treatment patterns. The most relevant studies have either examined a small data set pertaining to one region of the United States or have focused on one particular type of therapy or disorder, such as studies on schizophrenia (Busch, Frank, & Lehman, 2004; Dixon et al., 2001).
The research that is available is limited in both its scope of review and its list of providers. One study used 1998 payment schedules from Medicare and seven large managed care organizations to calculate the cost for 5, 10, and 15 psychotherapy sessions with a psychiatrist, a psychologist, or a social worker (Dewan, 1999). This study found that psychotherapy provided by social workers was the least expensive treatment, but it did not utilize outcome data from the payers, thereby limiting its ability to examine actual costs or treatment patterns.
Other studies have examined the number of sessions and cost by disorder, but do not break them down by profession. One such study examined data from 46 self-insured companies on 150,000 covered employees (Peele, Scholle, Kelleher, & Lave, 1998). It found that depression was the most frequent mental health diagnosis, followed by adjustment disorder, anxiety, and bipolar disorder. However, this study did not examine any differences among the mental health professions.
There is more research on the cost-effectiveness of family therapy versus individual therapy. One study examined Medicaid claims data from the state of Kansas on conduct-disordered youth receiving treatment over a 6-month period (Crane, Hillin, & Jakubowski, 2005). This study found that adolescents receiving in-office family therapy had total health costs that were 32% lower than those who received individual therapy only. Another study on the cost and use of Medicare ambulatory services examined outcome data from a random sample of 5% of Medicare claims from individuals who were diagnosed with schizophrenia (Dixon et al., 2001). The study found that family therapy had a lower mean cost per person than individual therapy. An additional study demonstrated that patients receiving family therapy reduced their use of medical visits (Law & Crane, 2000; Law, Crane, & Berge, 2003). Again, the studies here focused more on the type of service than the type of provider.
While there is little research comparing the costs and services provided by the different professions, the evaluation of services provided in this study is valid. Research demonstrates that state licensure laws show little variance among the studied professions and their ability to obtain an independent level of licensure or provide core mental health services (Hartley, Ziller, Lambert, Loux, & Bird, 2002, May). Each of the disciplines was evaluated according to a uniform standard, applying the established protocol for clinical mental health diagnosis and treatment. A mental health diagnosis was determined by employing the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 1994) published by the American Psychiatric Association, and the treatment protocol was selected from the Current Procedural Terminology (CPT), published by the American Medical Association. …