The costs of mental health services under the Fort Bragg Demonstration

This article examines the costs of treatment under the Fort Bragg Demonstration. It focuses on the direct costs of mental health services and suggests that expenditures on those services were much higher at the Demonstration. Increased access and greater "doses" of services provided at the Demonstration are identified as the proximal causes of the system-level cost difference. Consideration is given to whether these differences in costs and in service use can be attributed to the continuum of care per se or to differences in the financial arrangements under which care was provided. Supplemental analyses suggest that these expenditures were not offset by cost savings elsewhere. Implications for mental health policy are discussed.     

Clinical outcomes of a children's mental health managed care demonstration

The Fort Bragg Evaluation Project hypothesized that the mental health of children treated in the Demonstration's continuum of care would improve more than that of children receiving traditional mental health services at a comparison site. Program theory further predicted site differences in outcome for certain subgroups of children, such as those with severe mental health problems. These hypotheses were tested at 6-month and 1-year follow-ups in several ways, but results showed only slightly more site differences than expected by chance. For the evaluation sample of N = 984 treated children aged 5-17, site differences favored the Comparison about as often as the Demonstration. Children at both sites improved, but there was no overall superiority in mental health outcomes at the Demonstration.     

The quality of services in a children's mental health managed care demonstration

The Fort Bragg Demonstration and evaluation was designed to test the cost-effectiveness of a continuum of care model of service delivery for children and adolescents. A crucial aspect of the evaluation was the measurement of the quality of services provided in the Demonstration. Two key service components were examined: intake assessment and case management. It was concluded that these key components of the continuum of care were implemented with sufficient quality to have the theoretically predicted effects on mental health.     

The Fort Bragg Continuum of care Demonstration Project: The population served was unique and the outcomes are questionable

Examination of the evaluation sample and the outcome data from the Fort Bragg Demonstration Project suggests that the children served were mildly disturbed, were atypical of those served in most public mental health clinics, spent less than optimal time in the new services developed, and were judged as making considerable progress with minimal treatment regardless of age or level of judged psychopathology. The use of normative outcome measures in a pre-post design was considered a major reason for failure to find any significant differences between differently treated children.     

The Ventura Planning Model: a proposal for mental health reform

The Ventura Planning Model is a proposal for public mental health reform. It addresses the decline in mental health funding. It offers a rationale for increased support--and funding--for public mental health services. The Planning Model grew out of the experience of implementing and operating the Ventura Children's Demonstration Project. The model has five characteristics, or planning steps: 1) multi-problem target population; 2) systems goals; 3) interagency coalitions; 4) services and standards; and 5) systems monitoring and evaluation. The Ventura Children's Demonstration Project implemented these planning steps, with an infusion of $1.54 million in funds from the state legislature. The project offset at least 66 percent of its cost by reducing other public agency costs and improved a variety of client-oriented outcomes. The success of the project in offsetting its costs has led the legislature to provide additional funds for three more California counties to implement the model for children and youth, and $4 million a year for four years for Ventura County to test the model for adults and seniors. Emphasizing cost offsets in addition to client-oriented outcomes provides a practical rationale for proposing increases in public mental health funds. This rationale also implies substantial changes in the operations of many public mental health agencies.     

The evaluation of a children's mental health managed care demonstration

This article introduces the Fort Bragg managed care experiment. This study was a 5-year, $80 million effort to evaluate the cost-effectiveness of a full continuum of mental health services for children and adolescents. The article describes the development of the Demonstration, the program theory underlying intervention, and how this theory was tested.     

Methodological issues in evaluating mental health outcomes of a children's mental health managed care demonstration

A key question of the Fort Bragg Evaluation was whether the continuum of care model implemented at the Demonstration produced better mental health outcomes for children and adolescents than a traditional system of care. This article describes a few of the key methodological issues that were addressed to help ensure that findings about mental health outcomes were valid. The research design was quasi-experimental and longitudinal. Nearly 1,000 families participated, and attrition was low throughout the study. Multiple informants responded to a comprehensive array of widely used instruments in the area of children's mental health and mental health services. Despite the absence of random assignment, sites were comparable upon entry to the study on numerous factors that might affect outcome. Further, data lost through the course of study did not vary appreciably across sites. Finally, some evidence suggests that the findings of the Outcome Study may generalize to other populations of low-middle to middle-class youth in treatment.     

Medicaid managed care and the distribution of societal costs for persons with severe mental illness

OBJECTIVE: Managed care financing strategies that involve financial risk to insurers can reduce budgeted health expenditures. However, resource substitution may occur and negate apparent savings in budgeted expenditures. These substitutions may be important for individuals with disabling illnesses. The distribution of societal costs for adults with mental illnesses enrolled in plans that differ in their financial risk is examined to evaluate the degree to which risk-based financing strategies result in net savings or in the differential distribution of costs across public or private payers. METHOD: Six hundred twenty-eight adults with severe mental illnesses enrolled in three Medicaid plans that differ in financial risk arrangements were followed for 1 year to determine the distribution of resource use across Medicaid and other payers. Self-reported service use was obtained through interviews. Cost data were derived from self-reported expenditure, administrative, or agency data. Statistical procedures were used to control for preexisting group differences. RESULTS: Managed care was associated with a tendency toward reduced overall costs to Medicaid. However, private expenditures for managed care enrollees offset decreased Medicaid expenditures, resulting in no net difference in societal costs associated with managed care. CONCLUSIONS: Understanding the distribution of societal costs is essential in evaluating health care financing strategies. For adults with mental illnesses, efforts to manage Medicaid expenditures may result in substituting individual and family resources for Medicaid services. Government must focus on the distribution of societal costs since risk-based financing strategies may redistribute costs across the fragmented human services sector and result in unintended system inefficiencies.     

The Effect of Medicaid Managed Care on Mental Health Care for Children: A Review of the Literature

Despite its widespread adoption, little is known about the effect of Medicaid managed care (MMC) on children using mental health services. To assess the state of current research, we reviewed the literature on MMC and synthesized findings regarding access to care, expenditures, utilization, cost-shifting, and quality of care. A literature search was conducted and updated in November 2001. Studies were included if they involved evaluations of MMC, included children with mental health or substance abuse disorders, and had a non-MMC comparison group. Eight studies were included in the review. Most involved carve-outs and capitation. All of the studies that measured cost and service use showed decreases in total costs, inpatient care costs, and inpatient service use. These changes were frequently accompanied by increases in outpatient care. Some evidence suggests that MMC increased access to care for those with less serious conditions. There was no convincing evidence of cost-shifting from mental to physical health or other public agencies. Finally, no study directly measured health outcomes or quality of care. By reducing service use in inpatient settings, MMC has the potential to reduce children's mental health expenditures. The available research provides virtually no evidence on quality of care.     

Trauma-Focused Treatment in a State System of Care: Is It Worth the Cost?

The efficacy of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in treating child traumatic stress inspires nationwide dissemination, yet widespread adoption by state systems of care is lagging. A significant barrier is the cost of implementation and maintenance of evidence-based services. Thus, the current study examined the annual costs of mental health services accrued for 90 publiclyinsured, trauma-exposed children from the time they began participation in a TF-CBT implementation project to 1 year after their admission. These costs were compared to those accrued over that same time period by 90 trauma-exposed control children that were matched by demographics and prior mental health services utilization using a propensity score matching algorithm and provided outpatient treatment as usual. Results indicated that (a) 27.5 % of the total cost was attributed to high-end services utilized by only 1.67 % of children; (b) two times more money was spent on low-end mental health services received by the TF-CBT group than the control group, and (c) five times more money was spent on high-end mental health services received by the control group than the TF-CBT group in that year. These data suggest that providing evidence-based trauma-focused outpatient treatment to children with trauma-related problems may offset the eventual need for services that are more restrictive and costly.     

Age-Related Variation in Health Service Use and Associated Expenditures Among Children with Autism

This study examined differences by age in service use and associated expenditures during 2005 for Medicaid-enrolled children with autism spectrum disorders. Aging was associated with significantly higher use and costs for restrictive, institution-based care and lower use and costs for community-based therapeutic services. Total expenditures increased by 5 % with each year of age; by 23 % between 3–5 and 6–11 year olds, 23 % between 6–11 and 12–16, and 14 % between 12–16 and 17–20 year olds. Use of and expenditures for long-term care, psychiatric medications, case management, medication management, day treatment/partial hospitalization, and respite services increased with age; use of and expenditures for occupational/physical therapy, speech therapy, mental health services, diagnostic/assessment services, and family therapy declined.     

Public costs of better mental health services for children and adolescents

OBJECTIVE: This study evaluated how improved community mental health services for youths affect public expenditures in other sectors, including inpatient hospitalization, the juvenile justice system, the child welfare system, and the special education system. METHODS: Participants were youths aged six to 17 years who received services through a mental health agency in one of a matched pair of communities. One community delivered mental health services according to the principles of systems of care (N=220). The comparison community delivered mental health services but did not provide for the interagency integration of services (N=211). The analyses are based on administrative and interview data. RESULTS: Preliminary analyses revealed that mental health services delivered as part of a system-of-care approach are more expensive. However, incorporating expenditures in other sectors reduced the between-site gap in expenditures from 81 to 18 percent. This estimate is robust to changes in analytical methods as well as adjustments for differences between the two sites in the baseline characteristics of participants. CONCLUSIONS: These findings suggest that reduced expenditures in other sectors that serve youths substantially, but only partially, offset the costs of improved mental health services. The full fiscal impact of improved mental health services can be assessed only in the context of their impact on other sectors.     

Public vs. private insurance: Cost, use, accessibility, and outcomes of services for children with autism spectrum disorders

Very little research has been conducted on insurance type (private vs. public funded) and costs, accessibility, and use of services of children with autism. Analysis of five parent reported outcomes: (a) out-of-pocket expenditures, (b) variety of services used, (c) access to services, (d) child and family service outcomes, and (e) satisfaction with payer of services against private and public insurance was completed. Parents/caregivers completed a survey regarding recent usage of nine specific services—inpatient care, medication management, counseling or training, individual therapy, in-home behavior therapy, speech and language therapy, occupational therapy, case management, and respite care. Across all respondents (n = 107), 73.5% were privately insured; 21.2% were publicly insured. Based on insurance type, no statistically significant differences in outcome variables were found, findings that were not consistent with previous research. However, an indirect association was found between out-of-pocket expense and parent satisfaction with the payer of services, access to care, and family outcomes. Further, a significantly higher percentage of total out-of-pocket expenditures were allocated to speech language therapy among publicly insured children than among privately insured children (p = .03) and parent stress was a moderating variable between access to care and variety of services used.     

Correlates of therapy use and expenditures in children in the United States

Introduction: This paper describes correlates of use and expenditures for therapies (physical, occupational, speech or home health services) among children in the US.

Methods: It examined data from the Medical Expenditure Panel Survey, a nationally-representative US sample. The characteristics of users and described patterns of expenditures were examined.

Results: Use is quite low, only 3.8% of children use services or 4.3% once the use that occurs in the special education system is included. Children more likely to use therapy include those with presumably greater need: children with chronic conditions, functional limitations and/or a history of hospitalizations or injuries. There is a significant interaction of minority status and having a functional limitation. Expenditures are low when examined across the child population. Among a small proportion of high users, therapy expenditures account for a large proportion of overall health expenditures.

Conclusions: The educational system adds only slightly to the overall rate of use. In general use appears to be related to the need for such services. Some children, likely including racial/ethnic minority children, may under-use services. Lack of insurance is not related to less use, perhaps because there are other ways to get some services (family care or services provided through the public health system) or because not all insurers cover therapy services. Therapy expenditures account for a high proportion of overall expenditures among the high users of therapy whereas, for the entire child population, therapy expenditures account for a very small part of overall health expenditures.     

An Economic Comparison of Risperidone and Olanzapine Use within an Integrated Managed Mental Health Program

This study assessed differences in total mental health care costs for 1 year following initiation of risperidone or olanzapine in individuals within NorthSTAR, an integrated managed mental health pilot project. A retrospective database analysis of individuals with schizophrenia or schizoaffective disorder and newly started on either agent was conducted. Antipsychotic medication costs were significantly lower for individuals prescribed risperidone than olanzapine ($1763 versus $2582; p<0.001). Individuals prescribed risperidone had lower (but not significant) expenditures for mental health services ($4714 versus $5077; p=0.792), as well as total mental health care costs ($7407 versus $9011; p=0.255).     

Cost measurement and cost data in mental health settings

Costs play a major role in determining the types of mental health services that are delivered and thus are a key factor in any discussion of the future of mental health services. The author presents some of the available cost data for care provided in three kinds of settings: hospitals; nonhospital settings such as halfway houses, health maintenance organizations, and community mental health centers; and comprehensive community programs. He discussed the methodological and measurement problems in the estimation of costs and the difficulties in comparing costs across settings. He emphasizes the need for cost data that permit accurate an comparable predictions of costs that will assist policymakers in making intelligent choices between types of services.     

Cost and quality-of-life impacts of community treatment orders (CTOs) for patients with psychosis: economic evaluation of the OCTET trial

Purpose

Current RCT and meta-analyses have not found any effect of community treatment orders (CTOs) on hospital or social outcomes. Assumed positive impacts of CTOs on quality-of-life outcomes and reduced hospital costs are potentially in conflict with patient autonomy. Therefore, an analysis of the cost and quality-of-life consequences of CTOs was conducted within the OCTET trial.

Methods

The economic evaluation was carried out comparing patients (n = 328) with psychosis discharged from involuntary hospitalisation either to treatment under a CTO (CTO group) or voluntary status via Section 17 leave (non-CTO group) from the health and social care and broader societal perspectives (including cost implication of informal family care and legal procedures). Differences in costs and outcomes defined as quality-adjusted life years (QALYs) based on the EQ-5D-3L or capability-weighted life years (CWLYs) based on the OxCAP-MH were assessed over 12 months (£, 2012/13 tariffs).

Results

Mean total costs from the health and social care perspective [CTO: £35,595 (SD: £44,886); non-CTO: £36,003 (SD: £41,406)] were not statistically significantly different in any of the analyses or cost categories. Mental health hospitalisation costs contributed to more than 85% of annual health and social care costs. Informal care costs were significantly higher in the CTO group, in which there were also significantly more manager hearings and tribunals. No difference in health-related quality of life or capability wellbeing was found between the groups.

Conclusion

CTOs are unlikely to be cost-effective. No evidence supports the hypothesis that CTOs decrease hospitalisation costs or improve quality of life. Future decisions should consider impacts outside the healthcare sector such as higher informal care costs and legal procedure burden of CTOs.

     

Patterns of mental health service utilization in a general hospital and outpatient mental health facilities

Purpose Mental health is one of the priorities of the European Commission. Studies of the use and cost of mental health facilities are needed in order to improve the planning and efficiey of mental health resources. We analyze the patterns of mental health service use in multiple clinical settings to identify factors associated with high cost. Subjects and methods 22,859 patients received psychiatric care in the catchment area of a Spanish hospital (2000–2004). They had 365,262 psychiatric consultations in multiple settings. Two groups were selected that generated 80% of total costs: the medium cost group (N = 4,212; 50% of costs), and the high cost group (N = 236; 30% of costs). Statistical analyses were performed using univariate and multivariate techniques. Significant variables in univariate analyses were introduced as independent variables in a logistic regression analysis using “high cost” (>7,263$) as dependent variable. Results Costs were not evenly distributed throughout the sample. 19.4% of patients generated 80% of costs. The variables associated with high cost were: age group 1 (0–14 years) at the first evaluation, permanent disability, and ICD-10 diagnoses: Organic, including symptomatic, mental disorders; Mental and behavioural disorders due to psychoactive substance use; Schizophrenia, schizotypal and delusional disorders; Behavioural syndromes associated with physiological disturbances and physical factors; External causes of morbidity and mortality; and Factors influencing health status and contact with health services. Discussion Mental healthcare costs were not evenly distributed throughout the patient population. The highest costs are associated with early onset of the mental disorder, permanent disability, organic mental disorders, substance-related disorders, psychotic disorders, and external factors that influence the health status and contact with health services or cause morbidity and mortality. Conclusion Variables related to psychiatric diagnoses and sociodemographic factors have influence on the cost of mental healthcare.     

Children in foster care: Mental health, service use and costs

Abstract Objective To assess the prevalence of mental health problems in children in foster care, their families’ use of services and the associated costs. Methods Information on mental health problems, service use and costs was collected, by postal questionnaires and home interviews, on 182 children, their foster carers and teachers from 17 local authorities in Central Scotland. Results Over 90% of the children had previously been abused or neglected and 60 % had evidence of mental health problems including conduct problems, emotional problems, hyperactivity and problems with peer relations. When compared with 251 children from local schools, the children in foster care had significantly higher symptom scores for Reactive Attachment Disorder. Those children with highest scores for mental health problems were attracting a high level of service support from a wide range of agencies, except Child and Adolescent Mental Health Services (CAMHS). Costs were associated with learning disability, mental health problems, and a history of residential care. Conclusions Children in “mainstream” foster care are at greater risk of mental health problems, and are attracting greatest costs, but CAMHS are not successfully targeting these problems. CAMHS may need to develop new models of service delivery.     

Cost of care for Medicaid recipients with serious mental illness and HIV infection or AIDS

OBJECTIVE: To assist in developing public policy about the feasibility of HIV prevention in community mental health settings, the cost of care was estimated for four groups of adults who were eligible to receive Medicaid: persons with serious mental illness and HIV infection or AIDS, persons with serious mental illness only, persons with HIV infection or AIDS only, and a control group without serious mental illness, HIV infection, or AIDS. METHODS: Claims records for adult participants in Medicaid fee-for-service systems in Philadelphia during 1996 (N=60,503) were used to identify diagnostic groups and to construct estimates of reimbursement costs by type of service for the year. The estimates included all outpatient and inpatient treatment costs per year per person and excluded pharmacy costs and the cost of nursing home care. Persons with severe mental illness, HIV infection, or AIDS had received those diagnoses between 1985 and 1996. RESULTS: Persons with comorbid serious mental illness and HIV infection or AIDS had the highest annual medical and behavioral health treatment expenditures (about $13,800 per person), followed by persons with HIV infection or AIDS only (annual expenditures of about $7,400 per person). Annual expenditures for persons with serious mental illness only were about $5,800 per person. The control group without serious mental illness, HIV infection, or AIDS had annual expenditures of about $1,800 per person. CONCLUSIONS: Given the high cost of treating persons with comorbid serious mental illness and HIV infection or AIDS, the integration of HIV prevention into ongoing case management for persons with serious mental illness who are at risk of infection may prove to be a cost-effective intervention strategy.