Assessing Administrative Costs of Mental Health and Substance Abuse Services

Increasing competition in the market for mental health and substance abuse MHSA services and the potential to realize significant administrative savings have created an imperative to monitor, evaluate, and control spending on administrative functions. This paper develops a generic model that evaluates spending on administrative personnel by a group of providers. The precision of the model is demonstrated by examining a set of data assembled from five MHSA service providers. The model examines a differential cost construction derived from inter-facility comparisons of administrative expenses. After controlling for the scale of operations, the results enable MHSA programs to control the efficiency of administrative personnel and related rates of compensation. The results indicate that the efficiency of using the administrative complement and the scale of operations represent the lion's share of the total differential cost. The analysis also indicates that a modest improvement in the use of administrative personnel results in substantial cost savings, an increase in the net cash flow derived from operations, an improvement in the fiscal performance of the provider, and a decline in opportunity costs that assume the form of foregone direct patient care.     

Substance Abuse And Mental Health Services For Children And Adolescents

This study examines the initial effects of the Massachusetts Mental Health and Substance Abuse Program on 24-hour care for children and adolescents. Analysis of Medicaid claims shows that under managed care, access to 24-hour services, the number of service users, and admissions increased, while length of stay and expenditures decreased. The decomposition of the savings indicated that although the increase in admissions would have added an additional 2.7 million dollars to expenditures without managed care, the carve-out saved 9.1 million dollars in the first year through changes in length of stay, service settings, and price per day. The managed care variable was not significant in the regression models examining rapid readmission.     

Mental Health and Substance Abuse Services Preferences among American Indian People of the Northern Midwest

This study examines factors that influence preferences between traditional cultural and western mental health and substance use associated care among American Indians from the northern Midwest. Personal interviews were conducted with 865 parents/caretakers of tribally enrolled youth concerning their preferences for traditional/cultural and formal healthcare for mental health or substance abuse problems. Adults strongly preferred traditional informal services to formal medical services. In addition, formal services on reservation were preferred to off reservation services. To better serve the mental health and substance abuse treatment needs of American Indians, traditional informal services should be incorporated into the current medical model.Melissa L. Walls, Kurt D. Johnson, Les B. Whitbeck, Dan R. Hoyt are affiliated with the Department of Sociology, University of Nebraska-Lincoln, 711 Oldfather Hall, Lincoln, NE 68588-0324, USA; e-mail: mwalls@unlserve.unl.edu.This research was funded by the National Institute on Drug Abuse (DA13580) and the National Institute of Mental Health (MH67281), Les B. Whitbeck, Principal Investigator.     

Use of Mental Health and Substance Abuse Services Among High-Cost Medicaid Enrollees

Users of mental health and substance abuse (MH/SA) services were examined among nonelderly high-cost Medicaid enrollees in 10 states in 1995. Although MH/SA service users constitute 11% of all Medicaid enrollees, they make up nearly a third of high-cost enrollees. Adults account for two thirds of this high-cost MH/SA group, and most frequently qualify for Medicaid through disability-related eligibility categories. In contrast, a majority of children in the high-cost MH/SA group are eligible for Medicaid through child-related categories, rather than disability. In diagnostic makeup, the high-cost group was somewhat more likely to have serious disorders than the general Medicaid MH/SA user population.     

Provision of Mental Health Services in South African Substance Abuse Treatment Facilities

To date, South African research has not examined mental health service provision in substance abuse treatment facilities, even though these services improve client retention and treatment outcomes. To describe the extent to which substance abuse treatment facilities in Gauteng and KwaZulu-Natal provinces provide clients with mental health services during the course of treatment and to compare mental health service provision in these settings by type of facility and staff composition. Cross-sectional audits of substance abuse treatment facilities were conducted in Gauteng and KwaZulu-Natal provinces. Data were collected using the Treatment Services Audit Questionnaire. A response rate of 84% was obtained. Few treatment facilities provide clients with access to mental health services. Inpatient facilities are more likely than outpatient facilities to provide clients with access to mental health services. Facilities with for-profit ownership status are more likely than facilities with non-profit status to provide access to mental health care. Based on the above findings, a number of recommendations are made to increase the provision of mental health services during the course of substance abuse treatment.     

Adolescents with Substance Diagnoses in an HMO: Factors Associated with Medical Provider Referrals to Substance Abuse and Mental Health Treatment

This study examines the factors related to referrals of adolescents with substance use disorders to substance abuse or mental health treatment by their medical providers. Administrative and chart review data from the membership of a large private health maintenance organization (HMO) were collected from a probability sample of 400 adolescents, ages 13-18, who were diagnosed with a substance use disorder in 1999. Logistic regression analyses examined referral to substance abuse treatment and referral to mental health treatment in the aggregate and stratified by gender. Documented use of both alcohol and another illicit drug, and legal problems increased likelihood of referral to substance abuse and mental health treatment, whereas diagnoses of alcohol and marijuana use disorders decreased likelihood of referral to substance abuse treatment. Mental health diagnoses played a limited role in both types of referrals, although specific psychosocial problems were associated with increased likelihood of referrals. Treatment history and location of first mention of problem were significant predictors of referral. There were no gender differences in referral rates to either substance abuse or mental health treatment; however predictors of referral differed by gender. These findings extend our knowledge about factors that influence clinicians' treatment referrals of adolescents with substance abuse diagnoses and have implications for influencing clinician referral behavior within health plans.     

Unmet Need For Community-Based Mental Health and Substance Use Treatment Among Rural Adolescents

This research assessed the extent of unmet service need for rural youth with mental health (MH) and/or substance use (SU) problems. All adolescents (12–18 years old) living in a three-county region of Iowa and discharged from outpatient MH or SU treatment were included (n=177). Chart review was used to retrospectively assess service utilization and clinical characteristics at time of admission and discharge. Two-thirds (64%) of adolescents with co-occurring disorders did not receive treatment consistent with widely supported guidelines recommending that individuals with co-occurring disorders receive treatment for both their MH and SU problems. Higher severity of depression, more supports, prior MH service utilization and lower prevalence of prior abuse predicted the receipt of dual services. Finally, adolescents with co-occurring problems who received only MH treatment showed improvement on MH needs at discharge but no improvement on SU needs. Similarly, adolescents with co-occurring problems who received only SU treatment showed improvement on SU needs but not on MH needs. There is considerable unmet treatment need among rural adolescents with co-occurring disorders. Efforts to improve care must focus on adolescent, familial, program, funding and policy factors that act as barriers to unifying philosophies and practices needed to advance appropriate care.     

Knowledge Transfer,Policymaking and Community Empowerment: A Consensus Model Approach for Providing Public Mental Health and Substance Abuse Services

An important problem in creating new programs and polices is how to encourage the transfer of knowledge in non-hierarchical ways so that new, relevant and specific knowledge is co-created by all interested parties. In this paper, we suggest that a consensus model of policymaking is one response and identify four key structural elements thought necessary for creating such a consensus infrastructure. These are a) a leadership and facilitating capacity for initiating and promoting such an endeavor, b) a network or consortium of key researchers, practitioners, consumers, and policymakers to empower community ownership of the endeavor, c) a process for consensus building and strategic problem-solving for such a consortium, and d) the continued creation of a multi-directional dialogue through information dissemination. We examine these elements in action by describing a particular problem solving and consensus building model for developing and implementing a program, resolving group differences, and evaluating the group's process and products.     

Integrating Services for Schizophrenia and Substance Abuse

Over the past decade, several studies have attempted to determine whether integrating psychiatric and substance abuse treatment leads to better outcome for patients with comorbid schizophrenia and substance use disorders. A recent (1999) Cochrane Review (1) analyzed the effectiveness of prospective randomized studies of integrated treatment approaches, and concluded that there was no clear evidence for superiority of integrated treatment. This paper describes one such integrated treatment approach, in Beth Israel Medical Center's COPAD (Combined Psychiatric and Addictive Disorders) program. We summarize findings from an initial outcome study and a recent replication study; and describe clinical and research issues relevant to this population. Our data suggests the benefits of integrated treatment for patients with addictive disorders and schizophrenia, at least with regard to treatment retention. Clinical issues for such patients include identification of patients at risk, proper assessment and treatment planning, decision-making about mainstreaming vs. referral to specialized programs, and the importance of initial engagement and ongoing reengagement in successful treatment.     

The Need for Substance Abuse Training Among Mental Health Professionals

This study examines substance abuse as encountered by practitioners in six major mental health professions, from private practice to organizational settings. Respective national professional associations surveyed representative samples of their members, including psychiatrists, psychologists, professional counselors, social workers, marriage and family therapists, and substance abuse counselors. About one in five clients seen in private practice of mental health professionals had substance abuse disorders, with somewhat higher rates in organized mental health treatment settings. For a large majority of clients, substance abuse was secondary to a mental disorder. A significant minority of these practitioners reported having little or no training to address substance abuse, either from formal graduate education, internships, or continuing education.     

Mental and Substance Use Disorders Among Medicaid Recipients: Prevalence Estimates from Two National Surveys

This paper presents national estimates of behavioral disorders among Medicaid recipients. The 12-month prevalence of 14 disorders in the National Comorbidity Survey was 48% (43% mental, 14% substance use), and of 6 disorders in the National Household Survey on Drug Abuse was 27% (21% mental, 9% substance use). Total and specific disorder rates are from 50% to more than 100% higher in Medicaid than in the total population, and exceed most other insurance status groups. By promoting detection and treatment of these disorders in Medicaid, mental health administrators and policymakers may reduce barriers to education, employment, family stability, and departure from welfare.     

Utilization of Public Mental Health Services by Adults with Serious Mental Illness

Public mental health (MH) services were examined for non-elderly adults with serious mental illness (SMI) using a database combining information from Medicaid, MH, and substance abuse agencies in three states. These data show that between 23% and 39% of those with SMI received MH services only through Medicaid. Relative use of community versus state hospitals for delivery of psychiatric inpatient care varied across the three states. However, state hospitals accounted for a large proportion of total inpatient days, due to high mean annual days of care. In two states, Medicaid paid for fewer psychiatric inpatient days than expected.     

Prevalence of Mental Illness and Substance Abuse Disorders Among Incarcerated Juvenile Offenders in Mississippi

The prevalence of psychiatric disorders among incarcerated juveniles in Mississippi was examined. A total of 482 adolescents completed a diagnostic questionnaire and a subset (N = 317) was assessed with face-to-face semi-structured interview. Most of the study participants met criteria for one mental disorder, 71-85% depending on assessment method, one-third have co-occurring mental health and substance abuse disorders. Gender and placement site differences in rates of some psychiatric disorders were also noted. Routine mental health screening should be performed on all juveniles placed in secure detention facilities to identify those who need treatment services.     

Medicaid and African American Outpatient Mental Health Treatment

The present study tested the hypothesis that Medicaid-financed African Americans would be more likely to receive outpatient mental health treatment than African Americans whose treatment was financed by private insurance. The hypothesis was confirmed: when compared with privately insured persons eligible for care under either fee-for-service or managed care, the Black–White gap in outpatient service use was significantly smaller under Medicaid. There was no racial difference in outpatient treatment rates among the uninsured. The often-noted difference between Blacks and Whites in the likelihood of receiving outpatient mental health treatment is confined largely to the privately insured.     

Academic/State/Federal Collaborations and the Improvement of Practices in Disaster Mental Health Services and Evaluation

Academic, state, and federal agencies collaborated over the last 9 years to improve disaster mental health services and evaluation. This process, which included literature reviews, a number of expert panels, and case studies, is described. The products resulting from this process have included the development of a systematic cross-site evaluation of the federally funded crisis counseling program and field guides for interventions aimed at providing services to distressed individuals in the immediate aftermath of disasters and to individuals needing resilience skills training weeks or months after the event. Future improvement of disaster mental health services calls for continued research, evaluation, training, and intervention development.     

Substance Abuse Providers' Assessment of the Massachusetts Behavioral Health Program: Year 6

Substance abuse providers surveyed after Year 6 of the Massachusetts Behavioral Health Plan reported better treatment outcomes and access than in previous years. The Massachusetts Behavioral Health Partnership's clinical practices helped to improve quality of care. Its review process was highly rated. Coordination of substance abuse and mental health services was favorable, but was unfavorable with primary care. Staffing and organizational changes are described. Comparisons of outpatient and detoxification providers' responses with previous mental health and substance abuse surveys are made.     

Variations in Medicaid Mental Health Service Use and Cost for Children

Mental health care is a critical component of Medicaid for children. This study used summary tables drawn from the 1999 Medicaid Analytic Extract (MAX) files, the first available Medicaid data for the entire US, to examine fee-for-service Medicaid in 23 selected states. Data show that 9% of children and youth (ages 0-21) had a mental health-related diagnosis on a claim, varying from 5% to 17% across the states. The proportion increased with age, and was higher for boys. Over half of those diagnosed received psychotropic medication, and approximately 7% had an inpatient psychiatric admission during the year. Mental health costs accounted for 26.5% of total fee-for-service Medicaid expenditures, varying from 14% to 61% depending on the state.     

Managed Care and Service Capacity Development in a Public Mental Health System

Developing a continuum of care is considered to be one of the first steps in the process of implementing managed care strategies. This study summarizes the results of a final survey that focused on the ability of Colorado community mental health centers (CMHCs) to build service capacity and create new programs as a result of Medicaid capitation financing. Capitated agencies, compared to those that remained fee-for- service during the study period, reported a much greater ability to develop services as a result of capitation. Decreases in services were minimal for all agencies. Some differences in managed care organizational models were noted, as were differences in the speed of implementation. Gaps in some services still remain. These findings point to important program implementation issues for publicly funded managed care.     

Stigmatizing Attitudes About Mental Illness and Allocation of Resources to Mental Health Services

This study tests a social psychological model (Skitka & Tetlock, 1992). Journal of Experimental Social Psychology, 28, 491-522; [1993]. Journal of Personality & Social Psychology, 65, 1205-1223 stating that policy maker decisions regarding the allocation of resources to mental health services are influenced by their attitudes towards people with mental illness and treatment efficacy. Fifty four individuals participated in a larger study of education about mental health stigma. Participants completed various measures of resource allocation preferences for mandated treatment and rehabilitation services, attributions about people with mental illness, and factors that influence allocation preferences including perceived treatment efficacy. Results showed significant attitudinal correlates with resource allocation preferences for mandated treatment, but no correlates to rehabilitation services. In particular, people who pity people with mental illness as well as those that endorse coercive and segregated treatments, were more likely to rate resource allocation to mandated care as important. Perceived treatment efficacy was also positively associated with resource allocation preferences for mandated treatment. A separate behavioral measure that involved donating money to NAMI was found to be inversely associated with blaming people for their mental illness and not being willing to help them. Implications of these findings on strategies that seek to increase resources for mental health programs are discussed.