This chapter explores how primary care physicians deliver mental health treatment for Medicaid patients in one county in the United States, and how treatment may have changed after HMO enrollment with a mental health carve-out. We utilize Lipsky's theory of street-level bureaucracy to better understand how primary care physicians treat Medicaid patients for depression and what types of insurance arrangements support or inhibit that treatment. Exploratory interviews with 20 physicians revealed that the patient's status as a non-voluntary client, service system barriers and physicians’ commitment to treatment caused them to bear primary responsibility for the majority of depression care. Physicians were willing to act as advocates for their clients and viewed such advocacy as ethical given the lack of mental health parity. In general, primary care physicians were not familiar with new policies dictating mental health carve-outs for Medicaid patients, nor were they concerned with how mental health care was reimbursed for their patients. However, they were willing to provide mental health care even if they were not reimbursed. Physicians rely upon medication management to treat depression, and reimbursement plays a role in the amount of time spent with patients and in the coding used for the visit. Lipsky's (1980) theory of street-level bureaucracy provides a useful framework for understanding how physicians will act as advocates for their clients in the face of structural as well as resource constraints on health care.
Dunham, A., Scheid, T. and Brandon, W. (2008), "Physicians as advocates for their patients: Depression treatment in primary care", Jacobs Kronenfeld, J. (Ed.) Care for Major Health Problems and Population Health Concerns: Impacts on Patients, Providers and Policy (Research in the Sociology of Health Care, Vol. 26), Emerald Group Publishing Limited, Bingley, pp. 141-165. https://doi.org/10.1016/S0275-4959(08)26007-2Download as .RIS
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