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Online ISSN: 1099-176X    Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 21, Issue 2, 2018. Pages: 79-86
Published Online: 1 June 2018

Copyright © 2018 ICMPE.


Measuring Efficiency at the Interface of Behavioral and Physical Health Care

Parashar Pravin Ramanuj,1* Deborah M. Scharf,2 Erin Ferenchick,3 Brigitta Spaeth-Rublee,4 Harold Alan Pincus5

1MBBS BSc(Hons), MRCPsych, Consultant Psychiatrist, Royal National Orthopaedic Hospital & Senior Research Fellow, RAND Europe
2Ph.D., Lakehead University, Department of Psychology, Thunder Bay, Ontario, Canada
3M.D., Center for Family and Community Medicine, Columbia University Medical Center
4M.A., New York State Psychiatric Institute, New York, NY, USA
5M.D., New York State Psychiatric Institute, Irving Institute for Translational Research, Columbia University Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York-Presbyterian Hospital, New York, NY, USA

* Correspondence to: Dr Parashar P Ramanuj, Royal National Orthopaedic Hospital, London Spinal Cord Injury Centre, Brockley Hill, Stanmore, Middlesex, UK, HA7 4LP.
Tel.: +44-20-8909 5780
Fax: +44-20-8909 5748
E-mail: p.ramanuj@doctors.org.uk

Source of Funding: This publication was supported by the Commonwealth Fund (grant number 20141104). The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. Additional funding was provided by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant Number UL1 TR000040. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.


Background: Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both).

Aims of the Study: To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development.

Methods: We searched the Medline database for studies published in English in the last ten years with the terms `efficiency', `inefficiency', `productivity', `cost' or `QALY' and `mental' or `behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included.

Results: 85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31).

Discussion: Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes.

Limitations: We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified.

Implication for Health Care Provision and Use: Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care.

Implications for Health Policies: Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts.

Implications for Further Research: There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

Received 3 January 2017; accepted 27 April 2018

Copyright 2018 ICMPE