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Are publicly-insured psychiatric outpatients in Japan satisfied?
Health Policy 56 (2001) 205– 213 www.elsevier.com/locate/healthpol
Are publicly-insured psychiatric outpatients in Japan satisfied? Hiroto Ito a,*, Lloyd I. Sederer b a
Department of Health Care Economics, National Institute of Health Ser6ices Management, 1 -23 -1 Toyama, Shinjuku-ku, Tokyo 162 -0052, Japan b American Psychiatric Association, 1400 K Street, N.W. Washington, DC 20005, USA Received 24 March 2000; accepted 10 December 2000
Abstract Japan has a government financed outpatient program for people with mental disorders, called the ‘publicly-insured’ program. This study was performed to examine whether the target patient population used this publicly-insured program properly and to compare the degree of satisfaction of publicly-insured psychiatric outpatients with generally-insured psychiatric outpatients. The characteristics and satisfaction of 97 (43.9%) publicly-insured psychiatric outpatients and 124 (55.1%) generally-insured outpatients in Japan were studied. Psychiatrists rated sociodemographic and diagnostic information and patients were asked to complete the Japanese version of Client Satisfaction Questionnaire (CSQ-8J). The publiclyinsured were longer-term and lower functioning patients and were significantly more dissatisfied with the services they received than the generally-insured patients. The publicly-insured program was successful in that patients with lower functioning (the primary target population of this program) were cared for and because they received treatment for longer periods of time. However, the program does not sufficiently satisfy the consumers of the services, despite its high costs. In this respect, this program needs to focus more on patients’ points of view. More information on programs their enrollment procedures for patients may be helpful in educating consumers and citizens, clarifying expectations of services, and in influencing satisfaction. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Insurance; Mental health; Outpatient; Psychiatry; Satisfaction
* Corresponding author. Tel.: + 81-3-32035327; fax: +81-3-32026853. E-mail address: [email protected] (H. Ito). 0168-8510/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 8 - 8 5 1 0 ( 0 1 ) 0 0 1 1 6 - 6
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1. Introduction Services for the severe and persistently mentally ill are a major challenge in mental health policy and administration in all countries. Ensuring that the severe mentally ill patient receives care is further complicated by the downsizing of hospital beds, more mentally ill living in the community, and homelessness. Since this population is principally unemployed [1] and poor [2–4], governmental interventions to support this population, often financial support, is common in many countries. In the United States, for example, a significant percentage of people with mental illness receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) payments for their living expenses [1] and Medicaid and/or Medicare to cover their medical care [2]. In Japan, a government-financed program called ‘Livelihood Protection’ has financed a minimum standard of living, education and health care for the poor since 1950. Many patients with mental disorders are beneficiaries of this program. Both inpatient and outpatient care are paid without limitation as a part of this program. Since the number of psychiatric beds per capita (2.9 beds per 1000 population) is still high and the average length of stay is very long [5], another ‘publicly-insured program’ was established in 1965, in addition to Livelihood Protection, for outpatient mental health care. The eligibility criteria are rather inclusive: those who have mental disorders with certain symptoms including catatonic syndrome, hallucination and delusion, flattering of affect, and manic-depressive states [6]. The primary goal of this publicly-insured program is to provide benefits for the severe and persistently mentally ill even if they have economical barriers to continue outpatient care. Under this program, patients pay only 5% of outpatient costs; the local and national governments pay the remainder. These patients do not pay insurance premiums to finance coverage, unlike generally-insured patients who pay monthly premiums and co-payments of 20–30% when they receive care. Thus, there are three types of payments for the mentally ill under the age of 70 in Japan: (1) generally-insured payment (premium plus 20–30% co-payment); (2) publicly-insured outpatient payment (no premium but 5% co-payment); (3) Livelihood Protection (no premium and no co-payment). The average out-of-pocket payment for a single session for the publicly-insured would be about US$5 whereas out-of-pocket payment for government insurance is $20 –30. Most publicly-insured patients in Japan can afford $5 for treatment, and these co-payments are always collected. Mainous et al. [7], based on their survey to patients with general medical problems, indicated that low-income individuals are less satisfied with the care they receive. Since persons with severe mental illness often have a high level of economic and social disadvantage [8], it could be hypothesized that low-income individuals with mental illness would be more satisfied if there were no financial barriers to medical care. In addition, satisfaction could relate to compliance, which is defined as the extent to which a person’s behavior coincides with the medical advice given [9,10]. Since
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agreement between patients and providers was associated with higher levels of patient satisfaction [11], there could be some influence of compliance on satisfaction with care. It was hypothesized that: (1) publicly-insured patients were lower functioning, suffered from severe and persistent mental illness, and had a history of previous hospitalization; (2) because their health costs were lower (less economic burden), publicly-insured patients were more satisfied with the care they received than generally-insured patients; and (3) patients with higher compliance were more satisfied with care then those with lower compliance. In this study, one focused on comparison of the characteristics and satisfaction of outpatients covered by publicly-financed insurance and all other general insurance (which covers employees, self-employed, unemployed and public servants). The Japanese government has spent an enormous amount of money on this outpatient program. More than 200 million dollars were spent for about 365 000 publicly-insured outpatients in 1997, 59.1% of the annual budget for mental health [6]. There is, however, no official information on the clinical and socio-demographic characteristics of this program, and little is known about the beneficiaries’ satisfaction with services. At a time of government cost containment, this is a controversial program. Thus, it is important to examine the characteristics of the beneficiaries and their satisfaction.
2. Methods
2.1. Subjects Using random number tables, two not-for-profit, private psychiatric hospitals and two not-for-profit, private clinics each sampled 80 outpatients in 1998. Of the total 320 patients, 35 patients (10.9%) over 65 years old and 46 patients (14.4%) who did not participate or complete questionnaires were excluded. We also excluded 18 patients (5.6%) who were fully supported for both inpatient and outpatient care under Livelihood Protection. The subjects of the study were thus 221 patients (69.1%); 97 (43.9%) were publicly-insured patients and 124 (56.1%) generally-insured patients. The publicly-insured patients were supported only for outpatient care under this government-financed outpatient program.
2.2. Data collection procedure Psychiatrists also rated patients on the Global Assessment of Functioning (GAF) scale [12]. Sociodemographic and diagnostic information (gender, age, ICD-10 primary diagnosis, history of previous hospitalization, duration from initial psychiatric treatment, and compliance) were also provided by the psychiatrists. Compliance was evaluated by the psychiatrists by whether patients had taken medication regularly (consistent) or not (inconsistent).
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The psychiatrists also asked patients to complete the Japanese version of Client Satisfaction Questionnaire-8J (CSQ-8J), an eight-item questionnaire used to measure client satisfaction. Patients were informed that their responses to the questionnaire would be read and analyzed by independent researchers, not by hospital or clinic staff. All items of CSQ-8J were rated on 4-point scale according to the degree of satisfaction from 1 (dissatisfied) to 4 (satisfied). The total scores theoretically ranged from 8 to 32, with high scores (27 –32) indicating high satisfaction level [13]. The Japanese CSQ-8J has acceptable internal reliability and construct validity [14].
2.3. Analysis Differences between publicly-insured and generally-insured outpatients were analyzed using t-test for mean scores and chi square for categorical data. A level of PB 0.05 was considered as significant. Univariate and multivariate analyses of variance and multiple regression analysis were also used to examine factors contributed to the degree of satisfaction. The factors included in the analysis were age, gender, diagnosis (schizophrenia or not), the lowest and current mean GAF scores, history of previous hospitalization, duration from initial psychiatric treatment, site (outpatient in hospital or clinic), and compliance.
3. Results Of the 97 publicly-insured patients, 58 (59.8%) were male and 39 (40.2%) were female. The mean age (S.D.) was 38.9 (10.5) years old. The mean duration of treatment with their current psychiatrist was 4.2 (95% CI: 3.1 –5.4) years. Most of the publicly-insured (72; 74.2%) had consistent compliance, although inconsistent compliance was found in 25 (25.8%) patients. There were no significant differences between the publicly-insured and generally-insured patients in age, duration of treatment with their current psychiatrist, or compliance. As to gender, the rate of males in the publicly-insured patients (53; 42.7%) was significantly lower than that in the generally-insured patients (71; 57.3%, 2 = 6.33, df= 1, PB 0.05). Table 1 shows the characteristics of the publicly-insured and generally-insured outpatients. The publicly-insured patients were significantly more likely to have a primary diagnosis of schizophrenia (including schizotypal and delusional disorders); to have a lower GAF (Global Assessment of Functioning) score; and to have a history of previous hospitalization and longer duration of illness (measured from initial psychiatric treatment) than the generally-insured patients. The publicly-insured outpatients received treatment significantly more frequently at hospitals than at clinics. Although compliance did not differ significantly between the publicly-insured and generally-insured patients, the rate of schizophrenia in the publicly-insured patients with consistent compliance (55; 56.7%) was significantly higher than that of the generally-insured schizophrenic patients with consistent compliance (22; 17.7%, 2 =36.4, df= 1, P B0.001).
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Table 1 Characteristics and satisfaction of publicly-insured and generally-insured outpatients in Japan Publicly-insured patients (n = 97)
Generally-insured patients (n = 124)
73 (75.3) 24 (24.7) 29.2 (12.7) 61.2 (10.5)
35 (28.2) 89 (71.8) 45.7 (17.9) 71.8 (13.3)
2(1) =48.2a t (219) = 7.70a t (219) = 6.46a
63 (64.9) 19 (19.6) 15 (15.5) 10.7 (9.1)
37 (29.8) 73 (58.9) 14 (11.3) 6.2 (7.3)
2 (2) =35.7aa t (219) =4.06a
Outpatient in Hospital Clinic
66 (68.0) 31 (32.0)
34 (27.4) 90 (72.6)
2 (1) =36.3a
Compliance Consistent Inconsistent
72 (74.2) 25 (25.8)
91 (73.4) 33 (26.6)
2 (1) =0.89
Primary diagnosis Schizophrenia Other mental disorders The lowest mean GAF score (S.D.) Current mean GAF score (S.D.) History of pre6ious hospitalization Yes No Unknown Duration from initial psychiatric treatment (S.D.) in years
a
Test
PB0.001.
As shown in Table 2, the mean CSQ-8J score of the publicly-insured patients was significantly lower than that of the generally-insured patients. The rate of patients with high satisfaction level in publicly-insured patients (18.6%, n= 18) was significantly lower than that of generally-insured patients (30.6%, n= 38, 2 = 4.2, df= 1, PB 0.05). The CSQ-8J score did not differ between outpatients at clinics and Table 2 Satisfaction of publicly-insured and generally-insured outpatients in Japan
Satisfaction rated by CSQ-8J (S.D.)a Satisfaction by compliance (S.D.) Consistent Inconsistent Correlation coefficients between CSQ-8J score and GAF score (Kendall’s tau b) a
Publicly-insured patients (n = 97)
Generally-insured patients (n =124)
Test
23.3 (3.9)
24.8 (3.6)
t (219) =2.98b
23.8 (3.8)d 22.1 (4.1)d 0.10
25.5 (3.5)e 23.0 (3.1)d 0.20c
F (3, 21) = 8.2c 0.19c (n =221)
CSQ-8J indicates Client Satisfaction Questionnaire ([13]) and ranges between 8 and 32. The higher score indicates higher satisfaction. deMeans with the different superscript letters significantly differ from each other at PB0.05 (Bonferroni). b PB0.01. c PB0.001.
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Table 3 Regression analysis of CSQ-8J scores of publicly-insured and generally-insured outpatients in Japan
Age Gender (1: female, 0 male) Schizophrenia (1: yes, 0: no) The Lowest Mean GAF score Current Mean GAF score History of previous hospitalization (1: yes, 0: no) Duration from initial psychiatric treatment Outpatient in Hospital (1) or Clinic (0) Compliance (1: yes, 0: no) Constant
Publicly-insured patients
Generally-insured patients
i
t
i
t
0.06 0.03 0.15 −0.05 0.07 −0.10
0.48 0.24 1.3 −.36 0.62 −0.83
0.06 −0.01 0.07 −0.06 0.18 −0.10
0.64 −0.09 0.66 −0.46 1.7 −0.92
0.12 0.14 −0.19
0.83 1.3 −1.8 5.8c
0.11 −0.01 −0.26
1.1 −0.14 −2.9b 8.4c
R 2 =0.10 F (9, 87) =1.1
R 2 =0.16 F (9, 112) =2.4a
a
PB0.05. PB0.01. c PB0.001. b
hospitals in both publicly- and generally-insured patients. The generally-insured patients with consistent compliance were significantly more satisfied than the generally-insured patients with inconsistent compliance and for all of the publiclyinsured patients. The rate of patients with high satisfaction level in publicly-insured patients with consistent compliance (20.8%, n= 15) was significantly lower than that of generally-insured patients with consistent compliance (36.3%, n= 33, 2 = 4.6, df= 1, P B 0.05). There was no relationship between CSQ-8J score and GAF scores in the publicly-insured patients, whereas the generally-insured patients with higher GAF scores tended to be more satisfied. Multiple regression analysis showed that there were no significant factors related to CSQ-8J score in the publicly-insured patients while compliance contributed to CSQ-8J score in the generally-insured patients (Table 3).
4. Discussion In Japan, the government spends almost 60% of its mental health budget for the severe and persistently mentally ill to receive outpatient care. This program is mainly used by its target population, as this study indicates, who are long-term, lower functioning patients, principally diagnosed with schizophrenia. Publicly-insured patients received mental health care for an average of more than 4 years from the same psychiatrists. The mean duration from initial treatment to the present was 10 years. These results suggest that severely ill patients receive treatment under this government program, with its low economic burden, for lengthy periods of time.
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The high rate of schizophrenic patients in the program with consistent compliance among the publicly-insured patients provides important support for the program. In this regard, the program can be regarded as successful because it allows patients with mental illness who need long-term care to continue to receive outpatient care. Furthermore, the publicly-insured patients more frequently received treatment at hospitals than at clinics, and had more previous hospitalizations than the generallyinsured. Because in Japan the rate of new admissions to psychiatric hospitals is generally very low, these results suggest that former inpatients continue to receive after-care treatment at the same hospital. Unexpectedly, however, these publicly-insured patients are not satisfied with the services received, despite the financial benefits of the program. Contrary to the hypotheses, the publicly-insured patients were less satisfied than the generally-insured patients. Although the mean score and S.D. were close, significant differences were seen in the high satisfaction level using cut off point [13] in both total subjects and compliance-adjusted subjects. The fact that publicly-insured patients are not satisfied more than generally-insured patients is a problem because the government has supported specifically this target and expect their higher satisfaction to this program. The satisfaction of the generally-insured patients with inconsistent compliance, however, was similar to that of the publicly-insured. These results suggest that ‘the generally-insured patients with consistent compliance’ can be regarded as a different group from the others. In addition, the result of multiple regression analysis indicates that satisfaction is related to compliance and current GAF score in generally-insured patients, which is consistent with the previous research [11]. The result that the satisfaction of the publicly-insured patients was not sensitive to compliance, however, raises the question whether patients experience this program in coercive ways. Program eligibility is not clear to the patients, and psychiatrist and family decisions are more often influential than patient choices. In this study, we expected the publicly-insured patients to be more satisfied with services because they could receive the same services as generally-insured patients (based on freedom of choice), but with a smaller co-payment. Contrary to this expectation, the results indicate that government financial support is not sufficient to satisfy the consumers. Specific reasons for dissatisfaction in the publicly-insured patients were not identified in this study. Possible reasons for dissatisfaction in the publicly-insured patients include: (1) The stigma associated with public coverage [15]. In Japan, social stigma against mental illness is still great; patients (and their families) do not want to be regarded as the mentally ill. In addition, they may not want to be seen as poor or of lower social class, which being a beneficiary of a government program signifies. (2) Publicly-insured patients may believe that a lower co-payment means lower quality of care. Although there should not be differences in quality because of insurance type in Japan, this study did not compare quality. (3) Attitudes among doctors and hospital personnel that may result in patients experiencing their care in a critical or demeaning way.
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There are limitations to this study. The number of subjects studied was small and a cross-sectional study does not allow inferences about causality. Satisfaction is generally studied using cross-sectional data. The satisfaction of those who need the long-term care, like these publicly-insured patients, however, can change over time along with changes in symptoms, therapists, treatment, expectation for the program, and quality of life. Therefore, a longitudinal study is needed, with a greater number of subjects, as would more comprehensive measures, including patient wishes to be a program beneficiary, their expectations of the program and quality of care. The government program described here provides care for its target population, but these publicly-insured patients were not satisfied with the services they received despite the financial benefits. In Japan, doctors and hospital staff supply little information on programs to patients. Satisfaction measures the difference between what is expected and what is provided. Consequently, until patients are more fully informed about their care, measures of satisfaction may provide only limited information about the patient’s experience of care received. In Japan, government programs are often criticized for their bureaucratic procedures and use of public money. More information on the program (e.g. its clinical goals, eligibility, health care costs, and financial benefits for enrollee) as well as better clarification of enrollment procedures for patients may be helpful in educating consumers and citizens, and in influencing satisfaction. Simultaneously, performance assessment of measurable clinical quality goals will also help to reassure patients, families and the government that money is being well spent.
Acknowledgements Source of funding: Ministry of Health and Welfare, Japan.
References [1] Clark RE. Employment and security. Community Mental Health Journal 1995;31:493– 8. [2] Ginzberg E. Medical care for the poor: no magic bullets. Journal of the American Medical Association 1988;259:3309–11. [3] Saraceno B, Barbui C. Poverty and mental illness. Canadian Journal of Psychiatry 1997;42:285– 90. [4] Sleegers J, Spijker J, van Limbeek J, van Engeland H. Mental health problems among homeless adolescents. Acta Psychiatrica Scandinavica 1998;97:253– 9. [5] Ito H, Sederer LI. Mental health services reform in Japan. Harvard Review of Psychiatry 1999;7:208–15. [6] Ministry of Health and Welfare. Mental health and welfare in Japan: mental health and welfare handbook [In Japanese]. Tokyo: Kouken Syuppan, 1998. [7] Mainous AG, 3rd, Griffith CH, 3rd, Love MM. Patients satisfaction with care in programs for low income individuals. Journal of Community Health 1999;24:381– 91. [8] McAlpine DD, Mechanic D. Utilization of specialty mental health care among persons with severe mental illness: the roles of demographics, need, insurance, and risk. Health Service Results 2000;35:277–92.
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[9] Sackett DL, Haynes BR. Compliance with Therapeutic Regimens. Baltimore, MD: The Johns Hopkins University Press, 1976. [10] Kampman O, Lehtinen K. Compliance in psychosis. Acta Psychiatrica Scandinavica 1999;100:167– 75. [11] Perreault M, Rogers WL, Leichner P, Sabourin S. Patients’ requests and satisfaction with services in an outpatient psychiatric setting. Psychiatric Services 1996;47:287– 92. [12] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, American Psychiatric Association. Washington, DC, 1994. [13] Larsen DL, Attkisson CC, Hargreaves WA, Nguyen TD. Assessment of client/patient satisfaction: development of a general scale. Evaluation and Program Planning 1979;2:197– 202. [14] Tachimori H, Ito H. Nihongo-han Client Satisfaction Questionnaire 8 koumoku-han no shinnraise oyobi datousei no kentou [Reliability and validity of the Japanese version of Client Satisfaction Questionnaire]. Clinical Psychiatry 1999;41:711– 7. [15] Rodriguez E, Lasch K, Mead JP. The potential role of unemployment benefits in shaping the mental health impact of unemployment. International Journal of Health Services 1997;27:601– 23.
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Are publicly-insured psychiatric outpatients in Japan satisfied? Hiroto Ito a,*, Lloyd I. Sederer b a
Department of Health Care Economics, National Institute of Health Ser6ices Management, 1 -23 -1 Toyama, Shinjuku-ku, Tokyo 162 -0052, Japan b American Psychiatric Association, 1400 K Street, N.W. Washington, DC 20005, USA Received 24 March 2000; accepted 10 December 2000
Abstract Japan has a government financed outpatient program for people with mental disorders, called the ‘publicly-insured’ program. This study was performed to examine whether the target patient population used this publicly-insured program properly and to compare the degree of satisfaction of publicly-insured psychiatric outpatients with generally-insured psychiatric outpatients. The characteristics and satisfaction of 97 (43.9%) publicly-insured psychiatric outpatients and 124 (55.1%) generally-insured outpatients in Japan were studied. Psychiatrists rated sociodemographic and diagnostic information and patients were asked to complete the Japanese version of Client Satisfaction Questionnaire (CSQ-8J). The publiclyinsured were longer-term and lower functioning patients and were significantly more dissatisfied with the services they received than the generally-insured patients. The publicly-insured program was successful in that patients with lower functioning (the primary target population of this program) were cared for and because they received treatment for longer periods of time. However, the program does not sufficiently satisfy the consumers of the services, despite its high costs. In this respect, this program needs to focus more on patients’ points of view. More information on programs their enrollment procedures for patients may be helpful in educating consumers and citizens, clarifying expectations of services, and in influencing satisfaction. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Insurance; Mental health; Outpatient; Psychiatry; Satisfaction
* Corresponding author. Tel.: + 81-3-32035327; fax: +81-3-32026853. E-mail address: [email protected] (H. Ito). 0168-8510/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 8 - 8 5 1 0 ( 0 1 ) 0 0 1 1 6 - 6
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1. Introduction Services for the severe and persistently mentally ill are a major challenge in mental health policy and administration in all countries. Ensuring that the severe mentally ill patient receives care is further complicated by the downsizing of hospital beds, more mentally ill living in the community, and homelessness. Since this population is principally unemployed [1] and poor [2–4], governmental interventions to support this population, often financial support, is common in many countries. In the United States, for example, a significant percentage of people with mental illness receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) payments for their living expenses [1] and Medicaid and/or Medicare to cover their medical care [2]. In Japan, a government-financed program called ‘Livelihood Protection’ has financed a minimum standard of living, education and health care for the poor since 1950. Many patients with mental disorders are beneficiaries of this program. Both inpatient and outpatient care are paid without limitation as a part of this program. Since the number of psychiatric beds per capita (2.9 beds per 1000 population) is still high and the average length of stay is very long [5], another ‘publicly-insured program’ was established in 1965, in addition to Livelihood Protection, for outpatient mental health care. The eligibility criteria are rather inclusive: those who have mental disorders with certain symptoms including catatonic syndrome, hallucination and delusion, flattering of affect, and manic-depressive states [6]. The primary goal of this publicly-insured program is to provide benefits for the severe and persistently mentally ill even if they have economical barriers to continue outpatient care. Under this program, patients pay only 5% of outpatient costs; the local and national governments pay the remainder. These patients do not pay insurance premiums to finance coverage, unlike generally-insured patients who pay monthly premiums and co-payments of 20–30% when they receive care. Thus, there are three types of payments for the mentally ill under the age of 70 in Japan: (1) generally-insured payment (premium plus 20–30% co-payment); (2) publicly-insured outpatient payment (no premium but 5% co-payment); (3) Livelihood Protection (no premium and no co-payment). The average out-of-pocket payment for a single session for the publicly-insured would be about US$5 whereas out-of-pocket payment for government insurance is $20 –30. Most publicly-insured patients in Japan can afford $5 for treatment, and these co-payments are always collected. Mainous et al. [7], based on their survey to patients with general medical problems, indicated that low-income individuals are less satisfied with the care they receive. Since persons with severe mental illness often have a high level of economic and social disadvantage [8], it could be hypothesized that low-income individuals with mental illness would be more satisfied if there were no financial barriers to medical care. In addition, satisfaction could relate to compliance, which is defined as the extent to which a person’s behavior coincides with the medical advice given [9,10]. Since
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agreement between patients and providers was associated with higher levels of patient satisfaction [11], there could be some influence of compliance on satisfaction with care. It was hypothesized that: (1) publicly-insured patients were lower functioning, suffered from severe and persistent mental illness, and had a history of previous hospitalization; (2) because their health costs were lower (less economic burden), publicly-insured patients were more satisfied with the care they received than generally-insured patients; and (3) patients with higher compliance were more satisfied with care then those with lower compliance. In this study, one focused on comparison of the characteristics and satisfaction of outpatients covered by publicly-financed insurance and all other general insurance (which covers employees, self-employed, unemployed and public servants). The Japanese government has spent an enormous amount of money on this outpatient program. More than 200 million dollars were spent for about 365 000 publicly-insured outpatients in 1997, 59.1% of the annual budget for mental health [6]. There is, however, no official information on the clinical and socio-demographic characteristics of this program, and little is known about the beneficiaries’ satisfaction with services. At a time of government cost containment, this is a controversial program. Thus, it is important to examine the characteristics of the beneficiaries and their satisfaction.
2. Methods
2.1. Subjects Using random number tables, two not-for-profit, private psychiatric hospitals and two not-for-profit, private clinics each sampled 80 outpatients in 1998. Of the total 320 patients, 35 patients (10.9%) over 65 years old and 46 patients (14.4%) who did not participate or complete questionnaires were excluded. We also excluded 18 patients (5.6%) who were fully supported for both inpatient and outpatient care under Livelihood Protection. The subjects of the study were thus 221 patients (69.1%); 97 (43.9%) were publicly-insured patients and 124 (56.1%) generally-insured patients. The publicly-insured patients were supported only for outpatient care under this government-financed outpatient program.
2.2. Data collection procedure Psychiatrists also rated patients on the Global Assessment of Functioning (GAF) scale [12]. Sociodemographic and diagnostic information (gender, age, ICD-10 primary diagnosis, history of previous hospitalization, duration from initial psychiatric treatment, and compliance) were also provided by the psychiatrists. Compliance was evaluated by the psychiatrists by whether patients had taken medication regularly (consistent) or not (inconsistent).
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The psychiatrists also asked patients to complete the Japanese version of Client Satisfaction Questionnaire-8J (CSQ-8J), an eight-item questionnaire used to measure client satisfaction. Patients were informed that their responses to the questionnaire would be read and analyzed by independent researchers, not by hospital or clinic staff. All items of CSQ-8J were rated on 4-point scale according to the degree of satisfaction from 1 (dissatisfied) to 4 (satisfied). The total scores theoretically ranged from 8 to 32, with high scores (27 –32) indicating high satisfaction level [13]. The Japanese CSQ-8J has acceptable internal reliability and construct validity [14].
2.3. Analysis Differences between publicly-insured and generally-insured outpatients were analyzed using t-test for mean scores and chi square for categorical data. A level of PB 0.05 was considered as significant. Univariate and multivariate analyses of variance and multiple regression analysis were also used to examine factors contributed to the degree of satisfaction. The factors included in the analysis were age, gender, diagnosis (schizophrenia or not), the lowest and current mean GAF scores, history of previous hospitalization, duration from initial psychiatric treatment, site (outpatient in hospital or clinic), and compliance.
3. Results Of the 97 publicly-insured patients, 58 (59.8%) were male and 39 (40.2%) were female. The mean age (S.D.) was 38.9 (10.5) years old. The mean duration of treatment with their current psychiatrist was 4.2 (95% CI: 3.1 –5.4) years. Most of the publicly-insured (72; 74.2%) had consistent compliance, although inconsistent compliance was found in 25 (25.8%) patients. There were no significant differences between the publicly-insured and generally-insured patients in age, duration of treatment with their current psychiatrist, or compliance. As to gender, the rate of males in the publicly-insured patients (53; 42.7%) was significantly lower than that in the generally-insured patients (71; 57.3%, 2 = 6.33, df= 1, PB 0.05). Table 1 shows the characteristics of the publicly-insured and generally-insured outpatients. The publicly-insured patients were significantly more likely to have a primary diagnosis of schizophrenia (including schizotypal and delusional disorders); to have a lower GAF (Global Assessment of Functioning) score; and to have a history of previous hospitalization and longer duration of illness (measured from initial psychiatric treatment) than the generally-insured patients. The publicly-insured outpatients received treatment significantly more frequently at hospitals than at clinics. Although compliance did not differ significantly between the publicly-insured and generally-insured patients, the rate of schizophrenia in the publicly-insured patients with consistent compliance (55; 56.7%) was significantly higher than that of the generally-insured schizophrenic patients with consistent compliance (22; 17.7%, 2 =36.4, df= 1, P B0.001).
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Table 1 Characteristics and satisfaction of publicly-insured and generally-insured outpatients in Japan Publicly-insured patients (n = 97)
Generally-insured patients (n = 124)
73 (75.3) 24 (24.7) 29.2 (12.7) 61.2 (10.5)
35 (28.2) 89 (71.8) 45.7 (17.9) 71.8 (13.3)
2(1) =48.2a t (219) = 7.70a t (219) = 6.46a
63 (64.9) 19 (19.6) 15 (15.5) 10.7 (9.1)
37 (29.8) 73 (58.9) 14 (11.3) 6.2 (7.3)
2 (2) =35.7aa t (219) =4.06a
Outpatient in Hospital Clinic
66 (68.0) 31 (32.0)
34 (27.4) 90 (72.6)
2 (1) =36.3a
Compliance Consistent Inconsistent
72 (74.2) 25 (25.8)
91 (73.4) 33 (26.6)
2 (1) =0.89
Primary diagnosis Schizophrenia Other mental disorders The lowest mean GAF score (S.D.) Current mean GAF score (S.D.) History of pre6ious hospitalization Yes No Unknown Duration from initial psychiatric treatment (S.D.) in years
a
Test
PB0.001.
As shown in Table 2, the mean CSQ-8J score of the publicly-insured patients was significantly lower than that of the generally-insured patients. The rate of patients with high satisfaction level in publicly-insured patients (18.6%, n= 18) was significantly lower than that of generally-insured patients (30.6%, n= 38, 2 = 4.2, df= 1, PB 0.05). The CSQ-8J score did not differ between outpatients at clinics and Table 2 Satisfaction of publicly-insured and generally-insured outpatients in Japan
Satisfaction rated by CSQ-8J (S.D.)a Satisfaction by compliance (S.D.) Consistent Inconsistent Correlation coefficients between CSQ-8J score and GAF score (Kendall’s tau b) a
Publicly-insured patients (n = 97)
Generally-insured patients (n =124)
Test
23.3 (3.9)
24.8 (3.6)
t (219) =2.98b
23.8 (3.8)d 22.1 (4.1)d 0.10
25.5 (3.5)e 23.0 (3.1)d 0.20c
F (3, 21) = 8.2c 0.19c (n =221)
CSQ-8J indicates Client Satisfaction Questionnaire ([13]) and ranges between 8 and 32. The higher score indicates higher satisfaction. deMeans with the different superscript letters significantly differ from each other at PB0.05 (Bonferroni). b PB0.01. c PB0.001.
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Table 3 Regression analysis of CSQ-8J scores of publicly-insured and generally-insured outpatients in Japan
Age Gender (1: female, 0 male) Schizophrenia (1: yes, 0: no) The Lowest Mean GAF score Current Mean GAF score History of previous hospitalization (1: yes, 0: no) Duration from initial psychiatric treatment Outpatient in Hospital (1) or Clinic (0) Compliance (1: yes, 0: no) Constant
Publicly-insured patients
Generally-insured patients
i
t
i
t
0.06 0.03 0.15 −0.05 0.07 −0.10
0.48 0.24 1.3 −.36 0.62 −0.83
0.06 −0.01 0.07 −0.06 0.18 −0.10
0.64 −0.09 0.66 −0.46 1.7 −0.92
0.12 0.14 −0.19
0.83 1.3 −1.8 5.8c
0.11 −0.01 −0.26
1.1 −0.14 −2.9b 8.4c
R 2 =0.10 F (9, 87) =1.1
R 2 =0.16 F (9, 112) =2.4a
a
PB0.05. PB0.01. c PB0.001. b
hospitals in both publicly- and generally-insured patients. The generally-insured patients with consistent compliance were significantly more satisfied than the generally-insured patients with inconsistent compliance and for all of the publiclyinsured patients. The rate of patients with high satisfaction level in publicly-insured patients with consistent compliance (20.8%, n= 15) was significantly lower than that of generally-insured patients with consistent compliance (36.3%, n= 33, 2 = 4.6, df= 1, P B 0.05). There was no relationship between CSQ-8J score and GAF scores in the publicly-insured patients, whereas the generally-insured patients with higher GAF scores tended to be more satisfied. Multiple regression analysis showed that there were no significant factors related to CSQ-8J score in the publicly-insured patients while compliance contributed to CSQ-8J score in the generally-insured patients (Table 3).
4. Discussion In Japan, the government spends almost 60% of its mental health budget for the severe and persistently mentally ill to receive outpatient care. This program is mainly used by its target population, as this study indicates, who are long-term, lower functioning patients, principally diagnosed with schizophrenia. Publicly-insured patients received mental health care for an average of more than 4 years from the same psychiatrists. The mean duration from initial treatment to the present was 10 years. These results suggest that severely ill patients receive treatment under this government program, with its low economic burden, for lengthy periods of time.
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The high rate of schizophrenic patients in the program with consistent compliance among the publicly-insured patients provides important support for the program. In this regard, the program can be regarded as successful because it allows patients with mental illness who need long-term care to continue to receive outpatient care. Furthermore, the publicly-insured patients more frequently received treatment at hospitals than at clinics, and had more previous hospitalizations than the generallyinsured. Because in Japan the rate of new admissions to psychiatric hospitals is generally very low, these results suggest that former inpatients continue to receive after-care treatment at the same hospital. Unexpectedly, however, these publicly-insured patients are not satisfied with the services received, despite the financial benefits of the program. Contrary to the hypotheses, the publicly-insured patients were less satisfied than the generally-insured patients. Although the mean score and S.D. were close, significant differences were seen in the high satisfaction level using cut off point [13] in both total subjects and compliance-adjusted subjects. The fact that publicly-insured patients are not satisfied more than generally-insured patients is a problem because the government has supported specifically this target and expect their higher satisfaction to this program. The satisfaction of the generally-insured patients with inconsistent compliance, however, was similar to that of the publicly-insured. These results suggest that ‘the generally-insured patients with consistent compliance’ can be regarded as a different group from the others. In addition, the result of multiple regression analysis indicates that satisfaction is related to compliance and current GAF score in generally-insured patients, which is consistent with the previous research [11]. The result that the satisfaction of the publicly-insured patients was not sensitive to compliance, however, raises the question whether patients experience this program in coercive ways. Program eligibility is not clear to the patients, and psychiatrist and family decisions are more often influential than patient choices. In this study, we expected the publicly-insured patients to be more satisfied with services because they could receive the same services as generally-insured patients (based on freedom of choice), but with a smaller co-payment. Contrary to this expectation, the results indicate that government financial support is not sufficient to satisfy the consumers. Specific reasons for dissatisfaction in the publicly-insured patients were not identified in this study. Possible reasons for dissatisfaction in the publicly-insured patients include: (1) The stigma associated with public coverage [15]. In Japan, social stigma against mental illness is still great; patients (and their families) do not want to be regarded as the mentally ill. In addition, they may not want to be seen as poor or of lower social class, which being a beneficiary of a government program signifies. (2) Publicly-insured patients may believe that a lower co-payment means lower quality of care. Although there should not be differences in quality because of insurance type in Japan, this study did not compare quality. (3) Attitudes among doctors and hospital personnel that may result in patients experiencing their care in a critical or demeaning way.
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There are limitations to this study. The number of subjects studied was small and a cross-sectional study does not allow inferences about causality. Satisfaction is generally studied using cross-sectional data. The satisfaction of those who need the long-term care, like these publicly-insured patients, however, can change over time along with changes in symptoms, therapists, treatment, expectation for the program, and quality of life. Therefore, a longitudinal study is needed, with a greater number of subjects, as would more comprehensive measures, including patient wishes to be a program beneficiary, their expectations of the program and quality of care. The government program described here provides care for its target population, but these publicly-insured patients were not satisfied with the services they received despite the financial benefits. In Japan, doctors and hospital staff supply little information on programs to patients. Satisfaction measures the difference between what is expected and what is provided. Consequently, until patients are more fully informed about their care, measures of satisfaction may provide only limited information about the patient’s experience of care received. In Japan, government programs are often criticized for their bureaucratic procedures and use of public money. More information on the program (e.g. its clinical goals, eligibility, health care costs, and financial benefits for enrollee) as well as better clarification of enrollment procedures for patients may be helpful in educating consumers and citizens, and in influencing satisfaction. Simultaneously, performance assessment of measurable clinical quality goals will also help to reassure patients, families and the government that money is being well spent.
Acknowledgements Source of funding: Ministry of Health and Welfare, Japan.
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