Running head: PATHWAYS TO MEDICAL UTILIZATION
Manuscript 2003-0677
Pathways to Medical Utilization
William O’Donohue and Michael A. Cucciare
University of Nevada, Reno

Abstract
The role of psychologists in medical settings is evolving to include the development, delivery, and evaluation of psychosocial treatments for individuals who use disproportionate amounts of medical services. The primary purpose of this article is to present a model of psychological factors that drive health care utilization. A stepped care model of treatment delivery is also discussed along with a brief literature review depicting the impact of treatment approaches on high utilizing populations. This article concludes with recommendations for psychologists interested in providing treatment to medical utilizers.
Key words: Medical service utilization, health care utilization, high utilizers, integrated care

Pathways to Medical Service Utilization
Only 5% of federal dollars have been spent on behavioral health, while the U.S. spends approximately 1.4 trillion dollars on health care services (U.S. Department of Health and Human
Services, 2003). In 2003, increases in health care costs have risen at a rate of six times inflation
(Armour & Appleby, 2003). High utilizers are important contributors to the nation’s escalating health care costs. Increasingly, psychologists are being called upon to develop psychosocial interventions to address high medical service utilization. Consequently, the role of psychologists working in medical settings is evolving to include the development, delivery, and evaluation of psychosocial treatments for individuals who consume disproportionate amounts of medical services.
“High medical utilization” is a phrase used to explain the finding that large amounts of medical expenditures are concentrated in a relatively small segment of the population (Ash,
Zhao, Ellis, & Kramer, 2001; Anderson & Knickman, 1984; Liptzin, Regier, & Goldberg, 1980).
For example, Berk and Monheit (2001) found that the most expensive 1% of health care consumers accounted for 27% of total health care costs in 1996, the most expensive 5% accounted for 55%, and the top 10% accounted for 69%. Similarly, Ash et al. (2001) reported that health care costs for 1998 were highly skewed with the top .8% costing more than $25,000 per person while the median cost per person was $240.
The primary purpose of this article is to present a model of psychological factors involved in health care utilization. We will also present: (1) a discussion of various approaches to treatment using a stepped care model and (2) a brief literature review on the impact of various interventions on medical service utilization. This article will conclude with recommendations for psychologists interested in providing treatment to high utilizers.

Who are the High Utilizers?
Various psychological and medical conditions have been linked to high utilization of medical services (Liptzin et al., 1980). Garis and Farmer (2002) examined annual (for the year
1995) treatment costs of 284,060 Medicaid patients diagnosed with chronic psychological and medical problems. First, their results showed that the most expensive psychological problems to treat were (dollar amounts represent mean annual costs) some form of psychosis ($6,964) and depression ($5,505). The most expensive medical conditions to treat were cardiovascular disease
($2,320), congestive heart failure ($2,318), diabetes ($2,114), acid peptic disease ($1,811), asthma ($1,634), and hypertension ($1,351). The authors found that greater treatment costs for psychological problems was mostly due to expenditures for (a) treatment provided by nonphysician health care professionals (e.g., mental health) in the patient’s home and (b) hospital costs.
Second, mean annual treatment costs for patients with co-occurring psychological and medical problems was examined. The most expensive comorbid conditions to treat were psychosis and depression ($18,316), psychosis and anxiety ($10,425), psychosis and diabetes
($9,947), diabetes and acid peptic illness ($9,927), asthma and depression ($5,448), and acid peptic illness and anxiety ($5,099) (Garis & Farmer, 2002).
What “Drives” Medical Utilization?
Historically, some organizations, such as managed care companies, have attempted to control increasing costs by using “supply-side” strategies such as limiting the availability of health care services and improving treatment efficiency (Friedman, Sobel, Myers, Caudill, &
Benson, 1995). However, over the last decade, researchers have become interested in examining factors that impact the “demand-side” of rising costs (Cummings, 1997; Cummings, Cummings,

& Johnson, 1997; Friedman et al., 1995). Demand-side strategies focus on factors influencing a person’s need or decision to seek medical services. Many individuals seek medical services appropriately. Appropriate medical utilization takes place when an individual experiences the presence of physical symptoms that can be effectively treated by a health care provider and this need does not arise from the individual’s problematic behavioral patterns (e.g., seat belt usage, smoking, and poor dietary habits). However, Berkanovic, Telesky, & Reeder (1981) have shown that the presence of physical symptoms alone accounts for a small portion of variation in health care use. Factors such as age, socioeconomic status, and gender have been linked to utilization behavior (Borras, 1994). For example, Ash et al. (2001) have shown that factors such as age and sex can be useful in predicting future health care utilization and costs. These socio-demographic variables may be useful when developing algorithms that predict high utilization, however, they provide little information about what to do clinically as these variables are not readily modifiable.
Some models of health care utilization attempt to identify modifiable factors (i.e., motivation and poor lifestyle habits) that may be related to patterns of health care utilization. For example, the stages of change as outlined by the Transtheoretical Model (TTM) have been linked to significant changes in behavior that can have profound effects on health care utilization. The
TTM consists of five stages of behavior change (see Prochaska, DiClemente, & Norcross, 1992;
Velicer, Prochaska, Fava, Norman, & Redding, 1998).
1. The Precontemplation stage includes those individuals who are not intending to engage in behavior change within the future (i.e., the next 6 months). Factors such as lacking education or information about the impact of their behavioral patterns on their physical and psychological health, and feeling hopeless about changing their behavior successfully may be reasons for why

some individuals are in this stage. Traditional or action-oriented health care systems are not typically designed for these individuals.
2.
The Contemplation stage includes those individuals who are planning to engage in behavior change within the next 6 months. These individuals are aware of the advantages and disadvantages of engaging in behavior change. This awareness of the benefits and costs of changing can lead to ambivalence about engaging in behavior change. As a result, some individuals can remain in this stage for long periods of time. These individuals also do not respond to traditional action oriented health care systems.
3.
The Preparation stage includes individuals who are planning to engage in behavior change within the next month. The individuals have engaged in some significant act of change within the last year, and have a plan of action such as joining a educational class, consulting a health care provider, or buying a self-help book. These individuals are ready to change and should be recruited for action oriented programs such as a smoking cessation or weight loss programs.
4.
The Action stage includes those individuals who have made specific changes to their lifestyle within the past 6 months. It is important to note that in this stage, that not all “changes” in behavior are considered to be “action”. Only actions that are agreed upon by the appropriate professionals to educe risk of disease are considered. For example, to be “actions”, an individual must engage in smoking cessation or making significant reduction in fat intake.
5.
The Maintenance stage involves preventing the individual from relapsing back into behaviors that can negatively impact health. Individuals in this stage have engaged in significant behavior change for over 6 months and are less likely to relapse.

Vallis et al., 2003 empirically examined the validity of the TTM with a group of diabetic patients. Their results showed that as diabetic patients progressed from the preaction to the action stages, they tended to (a) eat healthier (e.g., consume less fat calories), (b) engage in healthier lifestyle habits (e.g., quitting smoking), and (c) displayed higher quality of life and lower daily stress than those patients in the preaction stages. Furthermore, patients in the maintenance stage were more likely to have had a diabetes education class within the past year, suggesting that some educational-based disease management programs may be effective in motivating some patients to change (e.g., educating patients on the advantages and disadvantages of a healthy lifestyle) and may subsequently reduce future utilization associated with unhealthy lifestyle habits (e.g., smoking, high levels of stress, and poor diet). However, this relationship is correlational and should not be interpreted as a reflection of a causal relationship. In addition, this conclusion is consistent with findings that show that diabetes psychoeducational programs that educate members on appropriate dietary changes and importance of metabolic control can lead to reductions in body weight, improved metabolic control, and healthier dietary habits
(Trozzolino, Thompson, Tansman, & Azen, 2003; Zapotoczky et al., 2001).
Psychosocial factors such as inadequate health information, attitudes and beliefs, unhealthy lifestyle habits, problems with treatment compliance, and levels of psychological distress can influence the need or decision to seek medical attention. For example, Cummings (in press) argues that “somatization” commonly results in high medical service utilization and therefore, developing appropriate programs for the somatizer should be a priority for any health care organization. Cummings (1997) defines somatization as the “translation of emotional problems into physical symptoms, or the exacerbation of a disease by emotional factors or stress
(pg. 4).” It is important to note that this definition differs from the Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association,
1994) definition of Somatization Disorder.
Psychosocial Pathways to Medical Utilization
It is estimated that between 60% and 70% of primary care medical visits result in no medical diagnosis (Melek, 2001). Specifically, Kroenke and Mangelsdorff (1989) found that less than 10% of patients presenting with physical symptoms such as chest pain, gastrointestinal complaints, and headaches actually had a physical cause. Friedman et al. (1995) suggest that psychosocial factors play a substantial role in health care utilization and present six psychosocial pathways that can impact health care utilization.
1. Information and decision support pathway . Many individuals are passive consumers of medical services and this style can result in unnecessary medical visits. This is can be due to a lack of information regarding effective strategies for self-management. Teaching individuals how to effectively discriminate between conditions requiring medical assistance and those that can be properly self-managed, as well as the actual skills to self-manage, can produce healthier people, particularly with patients suffering from chronic diseases such as diabetes (Ellenbecker,
Byrne, O’Brien, and Rogosta, 2002).
2. Psychophysiological pathway . There is a growing literature documenting the relationship between stress and the development and maintenance of many chronic medical conditions
(Lorig, Mazonson, & Holman, 1993). Heightened sympathetic arousal can exacerbate many chronic and acute medical conditions (Drummond, Finch, Skipworth, & Blockey, 2001).
Teaching individuals how to better manage stress (particularly the stress of long term management of chronic disease) can result in more effective disease management for illnesses such as diabetes (Cox & Gonder-Frederick, 1992).

3.
Behavior change pathway
. An individual’s lifestyle habits can contribute to the development of many chronic medical conditions. Changing behavioral habits such as diet, exercise, and smoking can have important and long-lasting effects on a person’s health and subsequent medical utilization (Hoie, Myking, Reine, & Bruusgaard, 1997; Robison, 1993;
Worcester, Stojcevski, Murphy, & Goble, 2003)
4. Social support pathway . It is common for individuals confronting medical problems to do so without sufficient social support (Friedman et al., 1995). Social support such as empathy and joint problem solving can moderate physical pain and ameliorate physical conditions (Evers,
Kraaimmaat, Greenan, Jacobs, & Bijlsma, 2003). Some individuals enter the health care system to not only gain access to medical services but also to access social support from medical providers.
5.
Undiagnosed psychological problem pathway . Many individuals presenting with physical symptoms have undiagnosed psychological conditions such as depression and anxiety, either at diagnostic or subclinical levels (Bixo, Sundstrom-Poromaa, Bjorn, & Astrom, 2001). Failure to identify and effectively treat these conditions can lead to increased medical utilization, as these conditions can exacerbate physical symptoms or interfere with treatment compliance.
6. Somatization pathway . Individuals presenting with frequent undiagnosed bodily complaints may be suffering from significant emotional distress such as worry, catastrophizing, feelings of hopelessness, and excessive attention to normal background noise (Cummings, in press; Friedman, 2003). These individuals often consume high amounts of medical visits that result in expensive diagnostic and treatment procedures that fail to provide any relief from emotional distress.

Although Friedman and colleagues provide excellent examples of general pathways to health care utilization, there are two problems with their outline of possible pathways: 1) they fail to specify many important details regarding pathway subtypes, and 2) they fail to mention other possible pathways to high utilization of medical services.
“Unpacking” Psychosocial Pathways to High Medical Service Utilization
Providing patients with type II diabetes information concerning diet, exercise, and other appropriate lifestyle changes can decrease medical utilization commonly associated with diabetes related complications (Cummings, Dorken, Pallack, & Henke, 1993; Sadur et al., 1999).
However, some individuals are resistant to these healthy lifestyle changes and as result exacerbate their chronic condition (Hahn, Teutsch, Rothenberg, & Marks, 1990). In the case of more difficult patients, the following questions become relevant: (1) why are some individuals resistant to lifestyle changes that can lead to a healthier lifestyle habits? and more broadly, what factors interfere with lifestyle change?
Bandura (1986) proposed the social-cognitive perspective that highlights the interaction between the environment, mental events, and our behavior in shaping our personalities. Bandura termed the interaction of these factors – reciprocal determinism . He argued that internal person factors (i.e., cognitions), environmental influences, and our behavior act as mutual determinants.
For example, in this view, depressed individuals may see the world as more “hopeless” than nondepressed individuals and subsequently react to the environment (e.g., a health care professional) by viewing behavior change (e.g., healthier diet and/or abstaining from alcohol) as meaningless, which can result in a vicious loop as they are resistant to future behavior change. The socialcognitive perspective stresses the interaction between internal personal factors and the environment, and their subsequent influence on future behavior.

The next section of this article will propose a similar model of behavior that attempts to specify the influences of “person and problems factors” and the influence of this interaction on medical resource utilization. Specifically, it is useful to conceptualize the problem of high health care utilization by examining the components of the following heuristic:
Person x Problem = Utilization of Medical Services
This model argues that the interaction between person factors (e.g., level of intelligence) and problem factors (e.g., diagnosable medical condition) largely contributes to the need or decision to utilize high amounts of health care resources.
Person Factors
The person component of the model refers to factors associated with the person’s psychological make up that may contribute to an individual being resistant to behavior change or needing health care services. Hippocrates said it is more important to know the person who has the problem than the problem the person has. Person factors include: level of intelligence, resistance to authority, values (e.g., failing to consider the importance of physical health), treatment resistance, assertiveness (or lack of), perfectionism, health beliefs, skills deficits, and problem solving capabilities. Consider the example of the anti-smoking campaign. For decades people have been bombarded with information concerning the negative health effects associated with smoking. Despite the many apparent informational-based deterrents (e.g., magazine adds, television commercials, and websites) available, many individuals continue to smoke cigarettes.
Person factors such as reactance to social authority (MacDonald & Wright, 2002), negative health beliefs (Thompson, Thompson, Thompson, Fredickson, & Bishop, 2003), and unassertiveness (Epstein, Botvin, & Spoth, 2003) contribute to continued smoking and eventual increased medical utilization.

Problem Factors
The problem component of the model includes clinical problems found in the ICD-10 or
DSM-IV multi-axial evaluation. This includes any clinically (or subclinical) diagnosable (e.g., depression or diabetes) conditions found on DSM-IV Axis I, II, or III. Also, Axis IV problems related to the patients social environment such as problems finding housing, lack of social support and education, and stress fit into this part of the heuristic.
The model proposed in this article stresses the interaction between the person and problem factors mentioned above. More specifically, intervening at the problem level (e.g., only providing information on disease management) or solely focusing on the DSM-IV Axis III diagnosis (i.e., only treating the medical problem) alone will not always be the optimal strategy for producing behavior change. Instead, a more comprehensive assessment and case formulation may be needed to more comprehensively identify factors leading to medical service utilization.
The person x problem equation attempts to illustrate how person factors can interact with problem factors to increase medical resource utilization. This model is analogous to the diathesis-stress approach (Pezawas et al., 2002) considered to be involved in the development of a variety of psychological conditions.
Application of the Person x Problem Model to a Clinical Example
A primary objective in analyzing the interaction between person and problem factors is to identify behavior chains that can lead a person to utilize increased medical services and then to effectively intervene at opportune points on that chain. Consider the following clinical example.
Joe has chronic asthma and experiences severe debilitating asthma attacks whenever he and his wife argue. Upon the initiation of these attacks, Joe asks his wife to drive him to the emergency room to receive treatment. Further information reveals that on the days he and wife argue, Joe

reports experiencing extremely stressful work related interactions and subsequently forgets to have lunch or take a break. In addition, Joe meets DSM-IV criteria for depression and antisocial personality disorder (APD) and therefore has difficulty following a treatment plan.
Identification of Person factors
Several person factors may contribute to Joe’s need for medical attention. First, he may have problems effectively communicating his needs (e.g., requesting emotional support) to others. Joe might come home from work and making excessive demands and/or requests from his wife, leading to arguments. Second, Joe’s stress may be exacerbated by lack of skills to manage time and poor problem solving capabilities. Furthermore, these skills deficits may make
Joe susceptible to stress, which in turn leads to irritability, triggers arguments with his wife and asthma attacks. Third, Joe may be treatment resistance. Factors such as his level of intelligence, resistance to authority, and impulse control may interfere with Joe’s ability to follow treatment instructions. For example, further assessment may reveal that Joe does not trust his health care providers and therefore does not adhere to treatment recommendations provided by them.
Furthermore, Joe may have values inconsistent with a healthy lifestyle and as a result, engages in risky behavior such substance abuse and absenteeism at work, which increase his stress and interfere with treatment adherence.
Identification of Problem Factors
Several problem factors may contribute to Joe’s need to for medical attention. First, Joe is suffering from chronic asthma and may lack useful information pertaining to the effective selfmanagement of asthma. Specifically, he may lack information pertaining to (a) appropriate lifestyle changes, (b) effective behaviors for managing asthma attacks, and (c) knowing how to effectively utilize health care resources when experiencing asthma related complications.

Questions such as, (a) when is it appropriate to call a health care provider?; (b) when is it appropriate to make an urgent care outpatient visit?; and (c) when is it necessary (or appropriate) to visit the emergency room? are relevant questions that Joe must understand.
Second, treatment nonadherence may be impacted by depressive symptoms such as chronic fatigue, sadness, problems sleeping, diminished ability to concentrate, and suicidal ideation
American Psychiatric Association, 1994; pg. 327). Third, behaviors consistent with APD such as difficulties constructing and following a plan, disregard for his health and well being, and repeated deceitfulness to his health care providers about the presence of asthma symptoms, may interfere with Joe’s (and his health care providers) ability to effectively manage his asthma.
Identification of Intervention Points
There are several treatments targets that can be addressed. First, Joe could receive
Cognitive-Behavioral Therapy to teach him how to more effectively assert his needs
(Duckworth, 2003). Second, treatment might focus on identifying factors responsible for Joe’s treatment resistance. Cummings and Sayama (1995) discuss the concept of implicit contract, which tells the clinician what the client actually wants from treatment (which may differ from the client’s stated goal). Resistance and mistrust of recommendations made by a health care provider may indicate Joe has other motivations (e.g., to appease his spouse) for seeking treatment. Cummings and Sayama suggest that treatment can be incapacitated if the discrepancy between the explicit reasons for seeking treatment and the implicit contract is too large. Third, brochures, telephone hotlines, and emails could provide Joe with information pertaining to the pathophysiology of asthma, what makes asthma worse, and how asthma is managed. Fourth, Joe could be triaged to anger or stress management groups. Joe could be taught relaxation exercises to help him more effectively regulate his emotional reactions to the environment. Lastly,

Depression and APD related substance use should be addressed. Cognitive Behavioral Therapy for depression (Beck, Rush, Shaw, & Emery, 1979; Burns, 1999) could be used to treat Joe’s depression. Also, Brooner, Kidorf, King, and Stellar (1998) suggest that substance-abusing clients with APD respond about as well to treatments for substance abuse as those without APD.
Modified Psychosocial Pathways
Many protocolized disease management programs focus primarily on the problem part of the model (see National Jewish Medical and Research Center, 2003a; American Healthways,
2003). For example, National Jewish Medical and Research Center (NJMRC) offers individuals education in the form of ongoing scheduled mailings, education booklets, and telephone hotlines, which reduce medical service utilization in some individuals (NJMRC, 2003b). However, at times, a more comprehensive approach may be needed to identify and treat important factors leading to medical service utilization.
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Table 1 provides a sample of pathways and treatment modifications to consider when using the proposed model. In the first column from the left, the psychosocial pathways presented by Friedman et al. (1995) are shown. A brief description of the elements leading to utilization is mentioned in the second column from the left. In the third column from the left, examples are given of intervention strategies for dealing with that problem. In the fourth column from the left, several modifications/additions are mentioned for dealing with person factors that may interfere with intervention effectiveness. Several of the same person factors may be relevant across diverse pathways. These include: level of intelligence, health beliefs, values, skills deficits,

treatment resistance, and lack of motivation. However, some person factors may be more relevant for a given pathway than others. In addition, similar interventions strategies (e.g., individual and group psychotherapy, psychoeducational groups, and educational/informational materials) can be used across person factors for each pathway. This table is not meant to be comprehensive in terms of pathways, problems, interventions, or person factors, but is provided to show a small sample of some kinds of person factors that are relevant to this model. The following examples depict how two pathways posited by Friedman et al. (1995) may be modified when considering the impact of the proposed model on individuals’ behavior.
Modified Information and Decision Support Pathway
Disease management programs that provide patients with education about managing a particular chronic disease can be useful. For example, Ellenbecker et al. (2002) developed a nursing clinic to promote health and disease management. The clinic provided screening, health education, outreach, and referral services to elderly diabetic patients. Results of the study showed that the percentage of elderly diabetics that were able to keep track of their blood sugar levels jumped from 54% (pre-treatment) to 73% (post-treatment). However, for some patients (the 27% intervention failures, e.g.), these types of information-based disease management programs may fail to change behavior (e.g., continue to over eat, smoke, and not exercise) and therefore other factors proposed in the person x problem model may need to be examined. Specifically, are problem factors such as low-energy, fatigue, problems sleeping, and/or the presence of
Borderline Personality Disorder interfering with the patient’s ability to better manage their chronic disease (e.g., follow a treatment plan or monitor blood glucose)? If yes, CBT for
Depression and Borderline Personality Disorder (Linehan, 1993) can be used to address these issues before the patient can engage in healthy disease management (e.g., exercise and treatment

adherence). In addition, are person factors such as negative health beliefs (Lai et al., 2002) and values interfering with the patient’s ability to engage in behaviors necessary in effective disease management? If yes, Cummings and Sayama’s (1995) approach for identifying and treating factors related to treatment resistance or Miller and Rollnick’s (2002) motivational interviewing may be conducted with the patient before a disease management group can be effective.
Modified Psychophysiological Pathway
Research shows that helping patient’s manage stress can reduce symptoms of psychopathology and health care utilization. The Harvard Personal Health Improvement Program
(PHIP), a 6-week (2 hour weekly sessions) psychoeducational group designed to teach high utilizing individuals skills for managing stress, has been shown to both effectively reduce psychological distress associated with high medical service utilization and to reduce medical utilization by as much as 50% (Locke et al., 1999). The 6-week course includes teaching and experiential components, training in meditation, daily homework, and collaboration with a partner.
This program emphasizes the problem factors and places less emphasis on how person factors, such as poor problem solving capabilities, low self esteem, and lack of motivation may influence a individual’s willingness to participate in such a program. Cummings, Dorken, Pallak,
& Henke (1993) managed the latter problem through an aggressive outreach program consisting of mail, telephone, and house calls by registered nurses. This approach was extremely successful in recruiting individuals into psychosocial treatments (e.g., groups) yielding a noteworthy 96.3% of the high utilizers identified.

Approaches to Intervention
The person x problem heuristic can have important implication for choosing appropriate level(s) of interventions. That is, by identifying specific points of intervention one can attempt to identify the clinical needs of the individual and reduce health care utilization. The following sections present a brief discussion of the stepped care model along with five approaches to intervention. A brief discussion of prevention is also presented.
In a stepped care model of treatment delivery, patients receive interventions along a continuum of care from least to most intensive (i.e., cost, professional intervention, and time commitment), based on considerations of problem severity, treatment responsiveness and cost.
Furthermore, stepped care attempts to match the individual’s treatment needs to the most efficient level of treatment. Stepped care takes seriously, and can be viewed as an attempt to implement the ethical dictum of the “least intrusive treatment”. For example, clinical problems such as treatment nonadherence or low level uncomplicated depression are first targeted through minimal care materials such as bibliotherapy (e.g., self-help books such as Burns, 1999) or psychoeducational groups. These types of interventions are considered first level care interventions and address clinical problems with treatments that are the least costly and invasive, and easiest to disseminate. This first step often uses interventions commonly found in public health. Examples of first level care interventions are illustrated in steps one and two in the following section. Second level care addresses clinical problems with health care providers such as nurses or social workers that make outreach phone calls or emails, conduct home visits and teach skills. Second level care employs professionals that use interventions that require more time and skill to administer than in first level care. Second level care is illustrated in step three in the following section. Finally, in third level care, clinical problems are addressed through the use

of maximized specialty care such as empirically supported treatments delivered by qualified health care providers such as doctoral or master’s level clinicians (Abrams et al., 1998). In third level care, treatment addresses both low and high prevalence problems such as personality disorders or depression and is tailored to address the individual’s specific behavioral health needs (e.g., personality disorders or substance abuse) of the individual. Examples of third level care are illustrated in steps four and five in the following section. It is important to note that it is consistent with this model to use more than one level of care for a given individual. Individual’s who do not improve at one level can be reassigned to a higher more intensive level.
Intervention approaches that target high medical utilization can orient toward six levels of intensity :
Prevention
Here the goal is either to identify those individuals who are not yet high utilizers but are at risk of becoming high utilizers by various predictor variables. The work of Ash et al. (2001) is oriented toward this modality. The goal is to identify predictors from claims data that will soon lead to high utilization and modify these factors so the pathway does not actualize. These interventions can also vary along the other five dimensions of intensity presented in Figure 1. A problem with this approach is that the prediction of high utilization is imperfect and thus it can make more sense to intervene with current high utilizers rather than attempt this prediction task.
However, Ash and colleagues might quickly point out that this criticism needs to be balanced with the reality that some of today’s current high utilizers even without intervention will soon become much lower utilizers do to regression to the mean.
As evidence for the effectiveness of this approach, Knowler et al. (2002) compared the extent to which (1) changing risk factors associated with the onset of diabetes (e.g., excess

weight and sedentary lifestyle) or (2) administering the drug metformin would prevent or delay the development of diabetes. Participants in the study were randomly assigned to three groups- lifestyle change, drug treatment, and placebo. Results showed that individuals in the lifestyle change group reduced their risk of developing Type 2 diabetes by 58%, and individuals in the drug treatment group by 31% when compared to placebo.
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Step 1: Informational Intervention Only
In this approach, high utilizers can be given brochures, access to web pages, and triaged to psychoeducational groups to provide them with information that may decrease utilization. The content of these materials can vary from information on how to manage their chronic disease to education about more appropriate utilization of the medical system (e.g., when to use emergency rooms v. when to call a health care provider). Psychologists with clinical skills to maximize the use of psychological mechanisms of change may design and evaluate the information provided to individuals but nonclinicians usually disseminate it.
One example of this approach is illustrated by the NJMRC (2003a). The NJMRC provides a variety of services designed to manage chronic disease (e.g., asthma) that vary from intensity depending on the needs of the individual. The low intensity program provides all patients with chronic conditions information pertaining to self-management of that condition.
Low intensity materials consist of ongoing scheduled mailings or emails, comprehensive educational booklets, and phone access to nurses that specialize in specific chronic conditions.
High intensity intervention services include telephone care and access to web-based strategies for

disease management. Specifically, individuals with more severe symptoms receive ongoing education that is tailored to their specific needs, access to a personal care manager 24 hours a day
7 days a week, customized telephone care, and ongoing communication between the disease manager and primary care physician.
As evidence for the effectiveness for this approach, the NJMRC reports that at 6-months post entrance into the program, adult asthmatics show a 68.6% reduction in ER visits, 71.5% reduction in hospitalizations, and 72.2% reduction in missed days from work when compared to baseline (NJMRC, 2003b).
Step 2: Informational Strategies, Minimal Decision Support, and Social Support
Commercial disease management programs, such as American Healthways (see
AmericanHealthways.com), utilize this approach. Using predictive modeling, patients are commonly outreached by telephone and supported while they make decisions about how to manage their chronic disease and decide what to discuss with their health care providers.
Problems with this approach include difficulties handling comorbid conditions such as depression or arthritis, lack of thorough diagnostic workups (i.e., psychological) and individualized treatment planning. Similar to step one, psychologists can take on the role of developing, implementing and evaluating these treatment programs, while other health care providers deliver the services.
American Healthways utilizes predictive modeling to identify those considered to be at high risk for chronic health problems. Once outreached, web-based physicians and customized treatment plans are used to provide treatment to individuals considered at risk for chronic illness.
Furthermore, American Healthways assigns a “patient care manager” to work directly with the patient and the patient’s primary care physician. Results of their diabetes management program

showed a 17.1% (or $114 per diabetic per month) reduction in total direct health care costs for the first year of program implementation. In addition, hospitalization costs were reduced by
15.9% (or $54.47 per diabetic per month) (American Healthways, 2003).
Step 3: Informational Strategies Plus Packaged Group Counseling
In this approach, high utilizers are given information about their chronic condition but are also commonly taught key skills in group therapy. The Harvard Personal Health Improvement
Plan is an example of this approach (see Locke et al., 1999). The assumption here is that there are some key skills that drive utilization such as poor diet, lack of exercise and stress management, and therefore successfully intervening on these targets can reduce overall utilization. Here psychologists can develop curriculum to target barriers to acquisition of key disease management skills.
McLeod, Budd, and McClelland (1997) studied the effectiveness of their 6-week group intervention (also known as Ways to Wellness and Personal Health Improvement Plan) that provides adjunctive treatment to primary care for persons suffering from physical symptoms with no identified medical etiology. Their group consists of weekly classes that involve homework, readings, meditation, classroom exercises, coaching, and out-of-class discussions with study partners. Group leaders are from a variety of health care fields including: nursing, social work, psychology, and medicine. The main objective of the group is to facilitate the acquisition of skills to better recognize physiological and mood states. Following treatment, participants had significantly lower scores on the depression, anxiety, and somatization subscales of the SCL-90R when compared to the control group. Also, outpatient medical utilization in the treatment group was reduced by 50%. These results maintained at 6 months following the end of treatment.
Step 4: Disease Focus “Vertical” Integrated Care

In this approach one common problem that cuts across utilization (such as depression) is targeted. High utilizing individuals are screened for depression and then given individual or group therapy. This approach is more clinically sophisticated and intense than any of the preceding strategies. However, one problem with this approach is that other common comorbid clinical problems such as substance abuse, anxiety, or borderline personality disorder are not addressed as a complete individual diagnostic evaluation is usually not given.
Cummings and his research team (1997) identified and outreached older adults shortly after the death of their spouse to screen for depression and severe (but not pathological) mourning. Those screening positive for signs of depression were triaged to psychotherapy while individuals in the latter group were referred to a bereavement group. The bereavement program focused on educating its members on the process of mourning, supporting members to experience mourning as painful healing, and teaching relaxation strategies and imaginary exposure to help manage the most painful periods. Psychologists ran all of these groups. Results showed that after two years, consumption of medical services was 40% higher in the control group when compared to the experimental group. Also, a medical cost savings of $1,400 per participant in the experimental group was found over two years post treatment.
Step 5: Full Clinical Focus
In this modality, skilled clinicians who are proficient in dealing with both health psychology problems such as treatment adherence, lifestyle change, and disease management as well as psychological disorders such as substance abuse, depression, anxiety, and personality disorders assess and treat a broad spectrum of pathways leading to high utilization. Treatment is individually tailored although high incidence problems such as depression might be addressed in

a group. However, treatment is still much more focused and problem oriented than in traditional specialty mental health (see Cummings & Sayama, 1995).
Cummings and a research team (1997) developed and evaluated the effectiveness of psychosocial groups for high utilizing Medicaid patients. High utilizing individuals were selected every month. The criterion for high utilization was defined as being in the top 15% of health care consumers. High utilization was defined by frequency of visits to a health care professional. The high utilizer group included patients with chronic diseases and psychological problems such as diabetes, hypertension, chronic airway and respiratory diseases, ischemic heart disease, rheumatoid arthritis, and depression. Once identified, high utilizers were recruited into disease specific psychosocial programs through an aggressive outreach protocol consisting of mail, telephone, and house calls by registered nurses. The results of the study revealed that the costs of developing the behavioral health care system were offset by the observed decrease in medical service utilization within 18 months. Also, Cummings and colleagues found a continued decrease in medical service utilization without the continued use of the behavioral health care program. In contrast, an increase of 17% to 27% increase in medical service utilization was found in the control groups. Psychologists ran all of these groups.
Conclusion
Increased health care costs incurred by high medical utilizers have an enormous impact on the rising costs of medical services. Psychologists have largely focused on the 5% of health care costs related to mental health and substance abuse, and have underutilized the behavioral health needs in the other 95% of the medical dollar. One role for psychologists in medical settings is to identify and address factors such as personality characteristics, comorbid psychological disorders, and problems resembling lack of social support that are related to

individuals’ consumption of medical services. This article presents a utilization model that emphasizes the interaction between person and problem factors and the consumption of health care services. Furthermore, this model focuses on the identification of treatment targets that have been shown to be amenable to psychological interventions. The outcomes of these interventions should lead to an increase in both psychological and physical health and to a natural (or no longer necessary) reduction in health care service utilization.
Several issues are relevant to psychologists interested in providing treatment to high utilizers. First, psychologists will need to market themselves to health plans and small medical practices. This might include (a) informing medical organizations such as insurers of one’s expertise and willingness to treat high utilizers (HUs) and address factors related to high utilization, (b) making agreements with other health care providers to refer, (c) demonstrating that one can address both the needs of the patient and the health care provider (e.g., provide effective treatments to reduce unnecessary patient visits), and (d) be able to deal with both acute and chronic behavioral health problems. This latter point means that psychologists working with this population will need to be competent in addressing a variety of clinical problems such as treatment nonadherence (Levensky, 2004), lack of motivation (Miller & Rollnick, 2002), and/or lack of social support (Brugha & Tyrer, 2003). Also, given the various medical problems HUs present to medical settings with, psychologists who take on HUs will need to familiarize themselves with the particulars of many common chronic medical conditions (e.g., asthma, diabetes, and chronic pain) they are interested in helping patients manage. Second, proximity to the referral sources is important. More and more psychologists are integrating into medical settings, such as physician practices or disease management organizations, which means that psychologists may need to rent space in (or in close proximity) to a medical building.

The model presented in this article is theoretical and therefore its clinical usefulness should be empirically examined. Future research might examine (1) cost effective assessment protocols to accurately and quickly capture the major variables associated with modifiable medical utilization, (2) triage protocols for the most cost effective funneling of individuals to the various levels of care, and (3) comparative research is needed to examine the cost-effectiveness, trainability, social acceptability, and differential treatment results of intervention technologies developed to treat person/problem factors related to increased medical service utilization.

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Table 1
Description of Psychosocial Pathways, Intervention Strategies, and Modifications/Additions for
Person Factors
Pathway Description
______________________________________________________________________________
Information/decision support Some individuals lack knowledge about the selfmanagement of chronic illness, importance of
Psychophysiological
Behavior change adhering to prescribed treatments, and the appropriate use of health care system.
Stress can lead to or exacerbate many chronic disease conditions.
Poor lifestyle habits can lead to or exacerbate many
Social Support chronic disease conditions. For example, poor diet, lack of exercise, and the use of alcohol or illicit drugs can impact a person’s psychological and physical health.
Some individuals confront medical problems without conjoint problem solving and emotional sharing. As a result, some individuals seek these from their medical provider(s) thereby using large amounts of unnecessary medical services.

Undiagnosed psychological problem(s)
Somatization
Some individuals present with physical problems and undiagnosed (or subclinical) psychological problems such as depression. The presence of psychological problems may lead to poor disease management and treatment nonadherence
Emotional reactivity can manifest (or exacerbate) into physical symptoms. Some of these individuals use large amounts of health care services with little or no relief from emotional or physical distress.

Table 1 (Continued)
Description of Psychosocial Pathways, Intervention Strategies, and Modifications/Additions for
Person Factors
Interventions strategies Modifications/additions needed to for dealing with pathway address person variables
______________________________________________________________________________
Educational materials including brochures, emails, and telephone contact to self-manage problems such as chronic disease (e.g., asthma)
Psychoeducation, biofeedback, and support
Assess and treat factors related to treatment resistance. These factors might include negative health beliefs (e.g., “I’m going to die anyway”) or values.
Assess barriers to attendance such as lack of groups targeting stress management; teaching patients to better manage physiological reactions to environmental stressors (e.g., relaxation training)
Classes, psychoeducational groups, and informational materials designed to educate patients on the consequences (e.g., exacerbation of chronic disease) of poor lifestyle habits. motivation or time and address these problems through aggressive outreach.
Other factors such as low self-esteem and negative health beliefs (e.g., “everyone deals has to deal with stress”.) may need to be addressed.
Assess barriers to behavior change such as skills deficits and poor problem solving capabilities. Lack of motivation or time may require motivational interviewing and teaching problem solving skills.

Provide access to social support through other means (e.g., support groups or psychotherapy).
Identify and treat psychological problems with effective psychotherapy and/or medication.
Identify and treat somatization in medical settings. Psychoeducation groups teaching the link between stress and physical symptoms can be used.
Assess and treat person factors interfering with accessing social support including problems being assertive and resistance to authority.
Target barriers to treatment seeking such as unhealthy beliefs or rules (e.g., “real men don’t need a therapist”). Aggressive outreach may be required.
Target factors contributing to somatizing behavior such as lack of skills to manage stress. Teaching the individual relaxation exercises may be needed before a psychoeducational group is effective.

Figure Caption
Figure 1.
Levels of interventions in the stepped care model

Level 1
Level 2
Level 3
Level 4
Level 5
Informational Interventions
Information + Minimal
Decision Support + Social
Support
Information + Packaged
Group Counseling
Disease Focus “Vertical”
Integrated Care
Full Clinical Focus