Cost shifting to jails after a change to managed mental health care

OBJECTIVE: To determine whether managed mental health care for Medicaid enrollees in King County, Washington, has led to indirect cost-shifting to substitute treatments, such as jails and state mental hospitals that are free goods to providers. DATA SOURCES: Complete service records for 47,300 adults who used at least one of the following systems from 1993 to 1998: King County jail system, Medicaid, or the King County mental health system. Data were also obtained from the Washington State Hospital System. STUDY DESIGN: A quasi-experimental analysis that compares the difference in outcomes between the pre- and post-managed care periods for Medicaid enrollees compared to non-Medicaid enrollees. The outcomes-jail costs, state hospital costs, and county outpatient mental health costs-were estimated with two-part difference-in-differences models. The regressions control for person-level fixed effects on up to 66 months of data per person. DATA COLLECTION METHODS: Administrative data were collected from the jail, Medicaid, and mental health systems, then merged and cleaned. Additional data on costs were obtained in interviews. PRINCIPAL FINDINGS: There is a striking increase in the probability of jail use for persons on Medicaid following the introduction of managed care. There was a significant decrease in expenditures in the county mental health system for outpatient care. CONCLUSIONS: Managed care led to indirect cost-shifting, probably through poor access to services, which may have led to an increased probability of jail detention.     

Outcomes for medicaid beneficiaries with schizophrenia under a prepaid mental health carve-out

This study examines the impact of a mental health carve-out program in Utah on mental health status of Medicaid beneficiaries with schizophrenia. Three community mental health centers contracted to provide mental health care for all Medicaid beneficiaries in their service areas under managed care arrangements, while beneficiaries in the remainder of the state remained under traditional Medicaid. A pre-post evaluation was utilized, with a contemporaneous control group of Utah Medicaid beneficiaries with schizophrenia under traditional Medicaid. From 1991 to 1994, the average beneficiary's mental health status improved, but the improvement was less under the carve-out program than under traditional fee-for-service Medicaid. The difference was the greatest for beneficiaries with the worst mental health status at baseline, with effects growing over time. Medicaid beneficiaries with schizophrenia experienced less improvement in mental health status under a carve-out arrangement for mental health care compared to what would have happened under traditional Medicaid.     

Substitution in a Medicaid mental health carve-out: services and costs

The objective is to empirically test the incentives associated with a Medicaid capitated mental health carve-out contract, whether outpatient services (less expensive, inside the contract) and residential treatment center care (costly care, outside of the contract) were substituted for inpatient psychiatric hospitalization used by children and adolescents. Data sources include Medicaid fee-for-service (FFS) claims for the non-capitated comparison sites and for residential treatment center use, and "shadow billing" encounter data for the experimental capitated managed care sites that provided public mental health services for children and adolescents with Medicaid insurance statewide in Colorado from September 1994 to June 1997. Two part least squares regression models are used to decompose services. Managed care sites are compared to sites that remained under FFS financing, before and in two post-periods after the carve-out. Principal findings show that children and adolescents who received mental health services from a capitated managed care provider were significantly less likely to receive inpatient care, and significantly more likely to receive residential treatment center care. In addition, insurance contract design contains financial incentives that affect the amount and mix of clinical care provided to clients by risk-bearing provider agencies. Findings provide evidence of cost substitution from inpatient care both inside the specialty system and outside the carve-out to other child-serving systems.     

Access of rural AFDC Medicaid beneficiaries to mental health services

This article examines geographic differences in the use of mental health services among Aid to Families with Dependent Children (AFDC)-eligible Medicaid beneficiaries in Maine. Findings indicate that rural AFDC beneficiaries have significantly lower utilization of mental health services than urban beneficiaries. Specialty mental health providers account for the majority of ambulatory visits for both rural and urban beneficiaries. However, rural beneficiaries rely more on primary-care providers than do urban beneficiaries. Differences in use are largely explained by variations in the supply of specialty mental health providers. This finding supports the long-held assumption that lower supply is a barrier to access to mental health services in rural areas.     

Specialty health care,treatment patterns,and quality: the impact of a mental health carve-out on care for depression

OBJECTIVES: To assess the effect of a mental health carve-out on treatment patterns and quality of care for outpatient treatment of depression. DATA SOURCES: Outpatient and pharmaceutical claims from September 1993 through March 1997 for one large managed care organization in the Midwest that carved-out mental health and substance abuse benefits in September 1995. RESEARCH DESIGN: Using the treatment episode as the unit of analysis (n = 1,747), changes in treatment patterns associated with the change to a carve-out were evaluated. Logistic regression was used to assess whether in the postperiod a treatment episode was more likely to be treated with (1) an antidepressant and (2) a type and intensity of treatment with proven efficacy. To strengthen confidence in a causal relationship, I search for structural breaks in treatment patterns across a wide range of dates, assuming no a priori knowledge of the timing of the impact of the carve-out. RESULTS: I find the carve-out to be associated with an increase in the use of drug treatments. Although I find a decrease in the use of guideline-level treatment over the entire study period, there is an increase in the number of episodes treated with guideline-level treatment over what would be the case in the absence of the carve-out. CONCLUSIONS: The increase in the use of drug treatments suggests previous research that excluded these costs may have overestimated the savings attributable to carve-outs. Guideline-level care appeared to increase as a result of carve-out implementation suggesting the use of management and specialization to reduce costs is not antithetical to quality improvement.     

Florida's medicaid mental health carve-out: Lessons from the first years of implementation

Florida, like many other states, has embarked on an experiment with managed mental health care for Medicaid enrollees. Under a 1915(b) waiver, the state's Medicaid agency began a mental health carve-out demonstration in March 1996 in the Tampa Bay area. This qualitative case study seeks to ascertain the impact of the carve-out (and, by comparison, HMO arrangements) on the public mental health sector. Findings suggest that the carve-out demonstration has succeeded in creating a fully integrated mental health delivery system with financial and administrative mechanisms that support a shared clinical model. However, other findings raise concerns about the HMO model in terms of stability, access to care, efficiency, and more generally about the shifting of risk and public responsibility downstream to private organizations without sufficient governmental oversight. These findings may offer guidance for other states implementing major managed care policy initiatives for disabled Medicaid enrollees.     

A population health framework for inner-city mental health

Dealing with mental health problems in the inner city presents a major challenge to planners and service providers. Traditional mental health service-oriented interventions often prove ineffective due to the complexity of individual's needs. This article argues that a population health framework can be used to identify critical risk and protective factors and facilitate more effective, upstream, population-based interventions for mental health problems in the inner city. A community report card is seen as a useful measure of key indicators at any point in time and of changes over time at the community or neighborhood level. A number of issues with regard to report card development are identified and discussed, as is the process of creating a report card, including key domains and the organization of findings.     

Effects of a mental health carve-out on use, costs, and payers: A four-year study

This study examines the effects of a mental health carve-out on a sample of continuously enrolled employees (N = 1,943) over a four-year time frame (1990–1994). The article presents a health care services utilization model of the effect of the carve-out on outpatient mental health use, cost, and source of payment in the three years post implementation relative to the year prior to the carve-out model. In the first three years of the carve-out, the likelihood of employees seeking mental health care increased in significant part because of the carve-out. For the outpatient mental health services user, the carve-out was not associated with the level of mental health services received. The carve-out was significantly associated over time with a reduction in the patient's and employer's mental health costs. This effect was more pronounced in the second and third years of the carve-out. The article explores the policy implications of these and other findings.     

Managed behavioral health care: a Medicaid carve-out for youth.

This DataWatch assesses the impact of a public sector-managed Medicaid mental health carve-out pilot for North Carolina youth. Access to, volume of, and costs of mental health/substance abuse services are reported. We compared a pilot managed care program, with an incentive to shift hospital use and costs to community-based services, with usual fee-for-service Medicaid. Aggregate data from Medicaid claims for youth (from birth to age seventeen) statewide are reported for five years. We found dramatic reductions in use of inpatient care, with a shift to intensive outpatient services, and less growth in mental health costs. These findings demonstrate that public sector-managed care can be viable and more efficient than a fee-for-service model.     

北京、青岛两市流动人口健康状况分析

目的：了解流动人口生活工作现况以及患病和求医行为。方法：采用定量和定性方法收集两地流动人口相关资料，应用SPSS10．0统计软件对数据进行分析。结果：被调查的993名流动人口妇女及其丈夫近两周患病率分别为10．4％和6．4％，患病后治疗率分别为61．4％和70．8％：被调查妇女5岁以下子女近两周感冒和腹泻患病率分别为11．2％和9．9％。最近一次患感冒和腹泻的治疗率分别为99．1％和83．6%。定性研究发现，流动人口患病后更多选择在私人诊所或药店买药治疗。结论：流动人口在现居住地生活艰辛，在健康方面是经过选择的群体。     

When mental health becomes health: age and the shifting meaning of self-evaluations of general health

Do self-evaluations of general health change as individuals age? Although several perspectives point to age-related shifts, few researchers have compared them. For this article, several competing hypotheses were tested using a large, nationally representative, and longitudinal data set. The results suggest two trends. First, the correspondence between functional limitations and self-rated health declines, especially after age 50. Similarly, the correspondence between various chronic conditions and self-rated health declines with age. These findings are consistent with social comparison theory. Yet, the results also suggest that the correspondence between depressive symptoms and self-rated health increases. Indeed, after age 74, the correspondence between self-rated health and some common symptoms of depression becomes stronger than that between self-rated health and several chronic, and often fatal, somatic conditions. This crossover has important implications for the detection and treatment of depressive symptoms in later life.     

Benefit flexibility,cost shifting and mandated mental health coverage

This paper presents a policy analysis of options for making a state’s mandated mental health benefit more flexible while maintaining insurance premiums at a constant level. The analysis illustrates the difficult choices facing legislatures that attempt to balance improved coverage for mental health care with concerns about rising health care costs. A sophisticated simulation model is used to assess the costs of four alternative insurance benefit design options.     

Inequalities in mental health in the working population.

Objectives: To analyze inequalities in mental health in the working population by gender and professional qualifications and to identify psychosocial risk factors and employment conditions related to the mental health of this population. Methods: We performed a cross-sectional study using data from the Barcelona Health Survey 2000. The working population aged 16-64 years (2322 men and 1836 women) was included. Mental health was measured with the General Health Questionnaire (GHQ-12). Adjusted odds ratios (aOR) and their 95% confidence intervals (CI) were calculated by means of multivariate logistic regression models separated by job qualifications and gender. Results: The prevalence of poor mental health ranged from 8% among men working in non-manual occupations to 19% in women working in manual jobs. Women were more likely to report poor mental health status than men, although sex differences were greater among manual workers (aOR = 2.26; 95%CI, 1.68-3.05 for women compared to men in the same group). Differences according to qualifications were found among women only (aOR = 1.58 [95%CI, 1.22-2.05] for women working in manual jobs compared to those working in non-manual jobs), while no differences were found among men according to qualifications. Psychosocial risk factors were associated with mental health: demand was associated in all groups, autonomy only in non-manual occupations, and social support only in the most highly qualified working women. Employment conditions such as working a split shift (working day with a long lunch break) or having a temporary contract were associated with mental health in manual occupations only. Conclusions: Mental health among the working population is related to professional qualifications and gender. Women are at greater risk than men, especially those working in manual occupations. Psychosocial occupational factors are related to mental health status, showing different patterns depending on gender and professional qualifications.     

Cost offset effect strategies for the provision of mental health care services

This analysis examines what is currently known about the financial efficacy of mental health services in relation to the cost offset effect in health care. Moreover, it suggests that the provision of mental health services should be intertwined with cost offset strategies in regard to its practice, research, and promotion. In doing so, policy decisions and ethical practices of care concerning mental health care delivery may be shaped within an adequate cost structure.     

妇幼保健机构群体保健服务项目成本核算

目的 了解不同经济发展水平地区的妇幼保健机构提供院外群体保健服务项目过程中的人力资源成本与物质成本.方法 利用全成本测算方法,对3个省级、3个市级和3个县级共9所妇幼保健机构提供院外群体保健服务项目的 总成本、工时成本和人均成本进行测算.结果 各项服务的成本与其开展服务内容的深度、辖区人口密度有很大的关系.2006年东部项目省群体保健服务项目人均成本为2.29元、中部省为1.23元、西部省为1.31元(按18个项目计算),3个项目省人均成本为1.61元.按该标准推算,2006年全国群体保健服务项目的 总成本为20.98亿元.结论 妇幼保健院外群体保健服务项目经费需要进一步提高.