Background
The impact of deinstitutionalization and the development of community treatment programs for people with serious and chronic mental illness have been frequently discussed for the last 40 years [
1,
2]. The issue regarding the cost-effectiveness for schizophrenics and caregivers has been given significantly more attention [
3‐
10]. Hence, the costs associated with schizophrenia have become an important issue for Taiwan's Bureau of National Health Insurance (BNHI) [
11]. The Kao-Ping Branch of the BNHI in Taiwan calculated the annual medical cost of schizophrenia in 2001 as 4.16% of the total medical budget (US$ 22,928,522/US$ 551,051,725). Therefore, apart from analyzing the utilization of medical resources among providers, the BNHI has also focused on an evaluation and comparison of medical outcomes.
Mental health services in Taiwan are determined partly by the BNHI, which makes overall plans for the national health insurance program, which is a social insurance structure. BNHI utilizes a fee-for-service reimbursement policy. Publicly and privately owned providers of mental healthcare services include general clinics, psychiatric wards of general hospitals, specialized psychiatric hospitals, chronic psychiatric hospitals, psychiatric rehabilitation institutions, day hospital admissions, and home visit services. Treatment plans among different organizations are similar but inconsistent, and lack a complete health network. There were a few patient referrals between organizations. Consequently, patients presented with minor problems at acute care hospitals, thus overcrowding hospitals and compromising the quality of care. Although a registration fee and a co-payment system apply to consultations in general hospitals, medication costs and examination co-payments continue to rise. However, schizophrenia is considered a severe disability under the BNHI guidelines, and patients are entitled to a severe disability card, which allows them to access medical services free of charge at any institution. This system not only increases accessibility to medical services for patients and their families, but also increases the utilization of medical resources. The BNHI has expressed concern over this situation, and has encouraged the establishment of a health network among health service organizations, to provide care to patients in a most cost-effective way.
This study was designed to compare the cost-effectiveness of an integrated treatment model consisting of a teaching hospital, psychiatric rehabilitation institutions, a day hospital, community rehabilitation centers, daycare farms, home-based care, and outpatient clinics, with those of the traditional treatment model provided by psychiatric hospitals or general acute care hospitals under the jurisdiction of the Kao-Ping Branch of the BNHI. We determined the differences in psychiatric resource utilization between these two treatment models with distinct management goals. The treatment outcomes of the two service providers were also explored in this study.
Discussion
The community-based network system of the current study provides a full service to help psychiatric patients develop skills for coping with the problem of living in the community and which virtually decreases hospitalization. Different to traditional hospital basis, community-based multidisciplinary teams are not only responsible for individual caseloads (case management) by homecare member, but also provide linking and coordinating services by a network system, that with a variety of community resources. This model shows how patients who would be treated in mental hospital can be successfully treated in the community without shifting the burden of care to their families. Despite the increasing costs of medication reimbursement, and the increased use of the community mobile team and outpatient clinic, the overall costs for the mental health system were substantially reduced.
The direct costs of care were found to be much lower than the costs in European countries. Average costs in Taiwan were US$ 2084 (US$ 2737 for the study group and US$ 2041 for the control group individually). Other countries reported the following associated costs: US$ 2693 in Spain [
22], US$ 15,859 in Mannheim, Germany [
23], US$ 32,003 in West Lambeth, England (which includes informal care costs) [
24], US$ 5678 in Italy [
25], and US$ 7656 in South Verona, Italy [
26]. When compared with USA, there is 1.56 times as much cost as that in Taiwan, with adjusted per capita income of the two countries. It shows that the average costs in Taiwan are further less than the costs in USA. In our study, the inpatient costs for the study group were 78% (acute 55.2%, chronic 22.2%) of the total health costs, and 66% (acute 30.17%, chronic 36.2%) for the control group; these costs seemed to dominate the overall service costs. Costs varied from 38% to 93%, and were variable internationally [
27]. Drug costs as a percent overall healthcare cost in our study were much higher than the drug costs in other counties. The average drug costs in this study were 25% of total direct healthcare costs, 14.6% in the study group, and 25.9% in the control group, when compared with the cost in other countries, which ranged from 2.3% to 13% [
27]. In an extended study of 10,972 cases across more than 10 countries in Europe, most patients were prescribed atypical neuroleptics at their first medical consultation [
22]. In all, a variation was found between the two groups in our study, and an evident variation was also found in European countries. Drug costs are expected to be proportionately higher in developing countries, compared with developed countries [
28]. Further evaluations are needed regarding the cause of the lower drug costs in the study group, the higher percentage of drug costs in Taiwan, and the percentage of prescriptions of atypical neuroleptics.
Many studies have discussed the reasons associated with the costs of schizophrenia. Compatible with previous findings, we found that the average length of stay (77 days) in the study group was longer than in the control group (64 days), and the average age of patients in the study group was 39.2 years, younger than the control group at 42.8 years old. The readmission rate in the acute ward of the study group (2.83 in 1 year) was much higher than in the control group (1.4 in 1 year), which might be why the direct costs of the study group were higher than those of the control group. The high readmission rate might suggest severe mental symptoms, lower GAF scores, higher BPRS scores, and lower income [
29]. According to the findings of this study (Tables
1 and
2), the higher costs of the study group might be due to the clinical differences of the cases.
The report by Knapp suggested that some costs were very difficult to determine. Although overall direct and indirect costs in the Knapp report added up to 2.6 billion euros, some indirect impacts were not measured, thus making the estimation of indirect costs a difficult task. According to the report published by the Department of Health, UK [
30], the costs for schizophrenia treatment were 5.4% of the total medical budget, and 3% of the total expenditure by the National Health Service [
31]. Generally, the direct costs of schizophrenia could be expected to be from 1.5% to 3% of the total national healthcare expenditure [
32‐
34]. In our study, the higher resource utilization of schizophrenic patients was 4.12% of the total healthcare resources of the Kao-Ping area, which might be due to Taiwan's social reform in recent years, in which the policymakers encouraged the development of mental health services that would elevate hospital ranking.
With respect to medical outcomes, we found that the following factors are often associated with a lower quality of life: sex (female), multiple episodes of schizophrenic psychosis, longer duration of the disease, and severe psychotic symptoms, such as with patients with higher BPRS scores [
35]. One study reported no differences in subgroups in terms of service utilization, quality of life, and the caregiver's emotional satisfaction between male and female patients [
36]. Many patients in Italy lived at home, with a hospital admission rate of 5.5%. They had a better quality of life when compared with patients in USA (with a hospital admission rate of 21%), because living at home meant greater residential stability, more ownership, and more people contacts [
37]. In this study, the poorer quality of life in the control group might be due to longer duration of hospital admissions and less home visiting. According to this study, the mental health provider should set up alternative services for the individual needs of patients and families of different genders, ages, and family incomes.
With regard to the families, our previous study revealed that an older age, a shorter duration of the disease, and severe psychotic symptoms were the predictors of a heavier burden on families [
35]. In this study, the factors that influenced the caregivers' burden were the longer duration of the disease and the low income of the caregivers. Further evaluation is needed regarding whether a different case sample, factor of poverty, demographic distribution, or interventions such as a study group, which have a higher service contact rate, would lower the family burden. In another study, psychological health and the burden on families were significantly associated with a shorter duration of the disease, showing that care giving created a burden on the family [
38]. In a study by the Connecticut Health Care System of the USA, patients with severe psychotic symptoms, living in the community, and with frequent family contact were correlated to a heavier family burden [
39]. Regardless of the type of service the patient received, the acute onset, severe symptoms, and frequent contact with the family were usually associated with a greater burden and mental stress. In the network of services in the study group, the continued follow-up of each patient may have been a better approach to decrease the family burden.
Inconsistencies were observed in family burden and CHQ scores, which may be due to the fact that family burden was more related to providing care for the patient, while the psychological health of the family was more related to secular changes. The CHQ scores were influenced by the age of the caregivers: the older they were, the lower the CHQ score (
p = 0.045, table not shown). Regardless of the type of care system, the caregivers were constantly under enormous psychological stress. As time passed, the CHQ scores of the caregivers increased, especially among the younger caregivers, which should be taken into consideration when using the CHQ as an outcome variable. The outcome variance due to multiple informants, such as that of the CHQ of the caregivers, cannot be ignored. Even self-rated satisfaction reports completed by parents are better predictors of the patient's satisfaction, and are more sensitive than changes in the patient's psychotic symptoms [
40,
41]. This indicates that the psychological status of the caregiver and the family should be further investigated when promoting the healthcare management of schizophrenia.
Competing interests
The author(s) declare that they have no competing interests.
Authors' contributions
Study concept and design: FWL.
Acquisition of data: DST, LCL, CUC, CYY, GTL, PP.
Analysis and interpretation of data: DST, LCL, CUC, CYY, GTL, PP, FWL.
Drafting of the manuscript: DST, FWL.
Critical revision of the manuscript for important intellectual content: DST, FWL.
Statistical analysis: DST, FWL.
Obtained funding: DST, FWL.
Administrative, technical, or material support: FWL.
Study supervision: FWL; FWL had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
All authors read and approved the final manuscript.