Many women who learn that they have breast cancer may experience severe anxiety, depression, shock, and disbelief. They face multiple medical consultations and treatment decisions, and they often must endure treatments that make them more vulnerable and cause considerable suffering.36
Moreover, they are forced to deal with the disfiguring consequences of treatments and the uncertain risks of recurrence and death. Because women cannot expect to require psychosocial care to deal with these challenges before they are diagnosed with breast cancer, their need for these behavioral health services is unexpected. For all these reasons, new or increased utilization of psychosocial services may occur.
We focused only on psychosocial services provided as part of the health plan behavioral benefit. These usually include screening, counseling, psychotherapy sessions, and medications (ie, antidepressant and antianxiety/hypnotic medications). We studied differences in utilization of these services between women who had breast cancer and who were enrolled in plans that provided behavioral health benefits via carve-out versus integrated arrangements. Our first hypothesis was that carve-out arrangements impede access to psychotherapy compared with integrated arrangements, because they increase fragmentation of care, introduce barriers to the access of psychotherapy, and create incentives to shift costs. We also hypothesized that women in carve-out arrangements received more antidepressant and antianxiety/hypnotic medications than women in integrated arrangements, because we thought medication therapy would substitute for psychotherapy in the carve-out setting.
Forty percent of all women who have breast cancer received some behavioral health care (ie, psychotherapy visits or antidepressant or antianxiety/hypnotic medications), which is greater than some aggregate need estimates.9,11
Women enrolled in carve-out arrangements were significantly less likely to receive any psychotherapy visits. Among those who did receive psychotherapy visits, women in carve-out arrangements used more visits than those in integrated arrangements. Hence, the carve-out arrangement appeared to limit access to psychotherapy services, but the number of psychotherapy visits was higher for women in carve-out arrangements once access was established. Moreover, women who had psychotherapy visits received significantly more antidepressants and antianxiety/hypnotic medications, which reinforced the fact that, once access to psychotherapy was established, women in carve-out arrangements used more behavioral health services. Perhaps women in carve-out arrangements had more visits and used more psychotherapeutic medications, because only those with the most severe problems were able to access behavioral health services.
Risk factors that have been associated with psychosocial distress among women who have breast cancer include younger age, more advanced cancer stage, impaired performance status, other comorbid medical conditions, inadequate social support, psychological distress, or a history of depression or other pre-existing mental illness.11
Young women may find the diagnosis harder to accept for several unique reasons: they view the illness as a rare, unexpected event, they face a poorer prognosis than older women, they may have dependent children, and they have to deal with the risk of infertility. We were able to control for age, comorbid conditions, and metastatic status as risk factors. We also controlled for the type of health coverage and the out-of-pocket costs of psychotherapy. Our results confirmed that younger age and more comorbid conditions are risk factors for the use of psychotherapy services. They also showed that poorer health status (measured by comorbidity diagnosis, metastatic status, and occurrence of an SAE of therapy) was associated with higher use of antidepressants and antianxiety/hypnotic medications. Although we expected that younger women would be more likely to receive psychotropic medications, we found the converse to be true. Prospective studies would better elucidate the relationship between psychosocial distress, age, and breast cancer.
We acknowledge limitations in this study. This population was restricted to women younger than 65 years who had employer-sponsored insurance. We had no information on race or ethnicity. Moreover, we used claims data, which provide less than optimal accuracy regarding each patient's health and behavioral health problems and possibly provide an incomplete picture of the services provider (because they focus only on what was billed). We also could not control for severity of mental illness, past use of behavioral services, income, or pre-existing provider relationships, as these data were not part of the Medstat data.
These results suggest that there is differential utilization of behavioral health services for women who have breast cancer and who receive their behavioral health services via carve-out versus integrated arrangements. Providers who care for women who have breast cancer and who refer patients for behavioral health services should realize that some patients experience more barriers than others when they try to access psychosocial services. Modification of carve-out contracts and administrative arrangements could permit more coordination between general health care and specialized cancer care and could correct for the differential utilization of behavioral health services provided by the current system. Allowing medical settings to bill carve-outs for behavioral health care, sharing the risk for complex cases (and/or adjusting case rates), and implementing performance standards aimed at complex cases are different approaches that could correct the distorted cost-shifting incentives, limited access to, and use of behavioral health services for women with breast cancer enrolled in a carve-out arrangements.18