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ESTIMATING the COST of PREVENTIVE SERVICES
in Mental Health and Substance Abuse Under Managed Care
Model Five: Presurgical Educational Intervention With Adults
This cost model was based on three research publications-Devine and Cook (1983); Devine, O'Connor, Cook, Wenk, and Curtin (1988); and Egbert, Battit, Welch, and Bartlett (1964)-and reviewed by Dorfman (2000) in references respectively numbered 35, 36, and 38. One publication (Devine and Cook, 1983) was a meta-analysis of 49 other studies. This meta-analysis and the other two studies described a variety of component interventions provided to adults undergoing a wide range of inpatient surgical procedures:
Nurse-conducted group workshops that focus on the benefits of psychoeducational supports, including written materials and videos
Presurgical and postsurgical visits by an anesthetist
Skill or exercise training to promote postsurgical recovery
Psychosocial support from a health care provider
Results
PMPM Cost
The median PMPM cost for the Least Expensive Scenario was $0.22. The median PMPM cost for the Most Expensive Scenario was $0.31, with a midpoint cost of $0.26.
Design and Input Values Used in the Model
Membership, Target Audience, and Level of Participation
The model begins with an estimation of the number of adults who would undergo an inpatient operative procedure. The number of operative procedures carried out in inpatient settings in the United States was accessed in the most recent results reported by the National Hospital Discharge Survey (NHDS; Centers for Disease Control and Prevention, 1996) and adjusted down by 71 percent, for an estimate of only those procedures done on adult and elderly patients (ages 18 to 80), the number of which was based on 1998 U.S. Census Bureau numbers. The 1996 inpatient surgical procedure rate was 154 per 1,000 members of the 1996 general population (U.S. Census Bureau, 1998). This value was reduced to 109 per 1,000 adult and elderly lives. The rate was reduced once again by the ratio of operative procedures in HMOs, as reported by the Group Health Association of America (1995), to the rate reported by the NHDS for the general population. HMO members in 1995 had about 36 percent fewer operative procedures than the general population. Therefore, the rate per 100,000 members in the hypothetical MCO was set at 70 per 1,000 adult and elderly lives (estimated at 71 percent of the 100,000).
The level of participation for the Least Expensive Scenario was set at 50 percent, increasing in 5 percent increments up to 65 percent for the Most Expensive Scenario.
Staffing and Materials
While the original research reports that an anesthetist made bedside visits to patients the night before the surgery, the model assumed that a nurse with specialty training in anesthesiology could carry out this task.
The Technical Appendix provides details of the assumed levels of participation for each component activity, the costs of the materials and supplies for each scenario, and the assumed time and effective cost per hour for the nurses, psychologists, nurse anesthesiologist, and health counselor.
Discussion
As in the case of Model 4, this intervention would seem relatively easy to incorporate into the routine operating procedures of most inpatient units. The biggest barrier might be the availability of a trained nurse anesthesiologist. But, given the reported effectiveness of this intervention in improving patients' medical compliance (Devine and Cook, 1983) and reducing the use of narcotics and the average length of inpatient stay (Devine et al., 1988; Egbert et al., 1964), the cost to implement such an intervention could be offset by savings for an MCO that is at risk for inpatient surgical costs.
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