Impact of capitation on clinical judgement in suicide risk assessment

The cost of mental health services has risen at an alarming pace in recent decades, making the need for cost-containment strategies unquestionable. The Aim of this study was to assess the impact of a capitated funding system (CPS)on clinicians’ judgment. As the focus on cost containment has been on inpatientservices, the variables which predict referral for inpatient care due to suicide risk in the six month period before and after implementation of CPS in a communitymental health center were examined. Variables coded from Mobile CrisisScreening forms were Age, Gender, Location of consultation, eight diagnostic categories. Examiner variables. Lethality at presentation, and four variables representing the Mental Status Examination (MSE). These served as controls or predictor variables. Capitation, represented by Time, was the independent variable of interest. Disposition was the dependent or criterion variable.A logistic regression analysis was performed entering all control variables in one step. The overall model at step one was significant (p<.0001). In the second step, the variable representing capitation was entered alone. The model remained significant (p<.0020). Thus, capitation contributed significantly beyond the influence of control variables in predicting referral for inpatient psychiatric hospitalization. An individual was nearly three times more likely to be referred forinpatient psychiatric care during the six months prior to capitation as compared to the six months following capitation, holding all other variables constant.IVIn the third step, product terms testing the significance of interactionsbetween Time and each of the following variables were entered; ExaminerDesignation, Disorientation-MSE, Psychotic Symptoms-MSE, Suicidal Ideation-MSE, and Lethality score at presentation. This set of interactions did not add predictive value to the model (p<.8166). The overall model of main effects instep two was therefore retained. The lack of significant interaction effects withTime appeared to suggest that capitation had a blanket effect on referraldecisions.These findings suggest that the capitated funding system influencedclinicians’ judgment regarding inpatient referrals in suicide risk assessments.Continued research is needed to explore and monitor the influences of fundingissues on clinical decision making, so that through awareness will developgreater containment.