Monitoring and Enforcing Cultural Competence in Medicaid Managed Behavioral Health Care

In recent years cultural competence has expanded beyond language provisions to include understanding and factoring into services provision the cultural perspectives clients may have that are different from the majority culture. The federal government requires state Medicaid programs to offer culturally competent services, but little is known about how states implement such mandates and monitor and enforce them. We reviewed the origins and implications of cultural competence mandates and conducted a brief case study of 5 states to learn about the implementation of cultural competence provisions in behavioral managed care contracts. We found that states and managed behavioral health organizations (MBHOs) vary in their definitions and implementation of standards to ensure mental health care access for vulnerable populations. Although states had a variety of oversight mechanisms, varying contractual requirements ranging from optional to required, vague contract language, no existing standardized indicators or definitions, and scant data on the cultural characteristics of the populations enrolled in Medicaid managed care hamper monitoring and enforcement of cultural competence by states. Implications for MBHOs, states, and the federal government, as well as services researchers, follow.     

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.     

A Comparison of Public and Privatized Approaches to Managed Behavioral Health Care for Persons with Serious Mental Illness

This article compares public and privatized approaches to managed behavioral health care for persons with serious mental illness in Massachusetts. Data from the Department of Mental Health (DMH) for 247 patients receiving care managed by DMH and 312 in a Medicaid carve-out were compared. Repeated measures multivariate analysis of variance models were used to examine adjusted changes in number of admissions, bed days, and facilities used from a baseline year before program implementation in 1992 through two follow-up years. Results were comparable for the two programs with similar reductions in the number of people receiving inpatient care but increases in admissions and bed days. Possible problems with continuity of care, indicated by individuals using multiple facilities, were identified for both. Given the evidence of comparable results, the choice between the two approaches is likely to be dictated by various pragmatic and subjective factors other than their demonstrated effectiveness.Dr. Dorwart is deceased, subsequent to the writing of this paper     

Overview Of Publicly Funded Managed Behavioral Health Care

Using MEDLINE and other Internet sources, the authors perform a systematic review of published literature. A total of 109 articles and reports are identified and reviewed that address the development, implementation, outcomes, and trends related to Managed behavioral health care (MBHC). MBHC remains a work in progress. States have implemented their MBHC programs in a number of ways, making interstate comparisons challenging. While managed behavioral health care can lower costs and increase access, ongoing concerns about MBHC include potential incentives to under-treat those with more severe conditions due to the nature of risk-based contracting, the tendency to focus on acute care, difficulties assuring quality and outcomes consistently across regions, and a potential cost-shift to other public agencies or systems. Success factors for MBHC programs appear to include stakeholder involvement in program and policy development, effective contract development and management, and rate adequacy.Mardi Coleman, B.A., is a Research Associate at the UMass Center for Health Policy and Research. William Schnapp, Ph.D., is a Professor at the University of Texas Medical School at Houston. Debra Hurwitz, M.B.A., B.S.N., R.N., is the Director, Sabine Hedberg, M.A., M.P.A., is a Project Director, Linda Cabral, M.M., is a Project Director, and Aniko Laszlo, M.A., M.B.A., is a Research Associate, all at the UMass Center for Health Policy and Research. Jay Himmelstein, M.D., M.P.H., is a Professor of Family Medicine and Community Health.Material for this article was developed in part to support a comprehensive evaluation of the MassHealth Primary Care Clinician Plan behavioral health carve-out, conducted by the University of Massachusetts Center for Health Policy and Research at the request of Phyllis Peters, M.B.A., Deputy Assistant Secretary for the MassHealth Office of Acute and Ambulatory Care.Address for correspondence: Mardi Coleman, B.A., UMass Center for Health Policy and Research, 222 Maple Avenue, Shrewsbury, MA 01545. E-mail: mardia.coleman@umassmed.edu.     

Outcomes for Rural Medicaid Clients with Severe Mental Illness in Fee for Service versus Managed Care

This study compared outcomes for rural Medicaid clients with severe mental illness in fee for service versus managed care programs. Interviews were conducted with 305 Medicaid clients in rural Oregon (166 in fee for service and 139 in managed care). Logistic and multivariate regression analyses were used to examine client satisfaction, safety, symptoms, functioning, and family satisfaction in the fee for service versus managed care groups. There was no evidence that conversion of the Medicaid mental health system from fee for service to managed care led to changes in outcomes for rural clients with severe mental illness.     

Cost-Shifting in Managed Care

We conducted a study of the change from fee-for-service to managed care for mental health services in the Massachusetts Medicaid program, which occurred in fiscal year 1993. We estimated the effect of managed care on total public expenditures over both the short and the long term. Per person expenditures were lower by 24% in the first year of managed care but only lower by 5% in the second and third years. We also tested for cost-shifting by estimating expenditures for five specific services paid by three public agencies. Expenditures on services paid by the managed care vendor decreased, expenditures paid by Medicaid increased, and expenditures paid by the Department of Mental Health decreased. We discuss the implications for both cost-shifting and quality of care improvements. The results from two-part expenditure models indicate that some cost-shifting may be related to quality improvement. The effects are generally stronger for the beneficiaries in the highest quartile of expenditures.     

Access and Service Use by Children with Autism Spectrum Disorders in Medicaid Managed Care

Although Medicaid is the largest public payer of behavioral health services, information on access and utilization of services is lacking, and no data on the frequency of service use or types of services provided for children with autism spectrum disorders (ASDs) are available. As states move toward managed care approaches for their Medicaid program, services information is critical. Behavioral health service data for children with autism spectrum disorders were collected from a state Medicaid Managed Care (MMC) program and analyzed from fiscal years 1995 through 2000. Findings revealed that the number of children who received services over time increased significantly; however, the rate of service use was only one tenth of what should be expected based on prevalence rates. The mean number of service days provided per child decreased significantly, about 40%, and the most prevalent forms of treatment changed. Day treatment vanished and medication and case management increased disproportionately to the number of children served. Explanations and implications of the findings are presented as well as recommendations for future research.     

Crossing The Divide: Primary Care And Mental Health Integration

This paper describes the views of primary care providers about treating depression among adult Medicaid patients and their experiences with managed behavioral health care. It also shows the outcomes of an intervention project that provides a care manager to facilitate connections among PCPs, patients, and behavioral health providers. Despite widespread initiatives to improve depression management in primary care and to manage behavioral health services, it appears that links between the two systems and the use of evidence-based approaches to managing patients are rare. A pilot project to initiate practice redesign, the use of a care manager to assist in patient support, and compliance with both medical and behavioral health treatment has been shown to improve communication and results in positive patient outcomes. Managed behavioral health care can result in incentive structures that create gaps between primary care and behavioral health systems. This project illustrates an initiative co-sponsored by the Massachusetts behavioral health program designed to strengthen links between behavioral health and primary care, and increase rates and effectiveness of depression treatment.     

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.     

Assessment,Authorization and Access to Medicaid Managed Mental Health Care

Examined were effects on access of managed care assessment and authorization processes in California's 57 county mental health plans. Primary data on managed care implementation were collected from surveys of county plan administrators; secondary data were from Medicaid claims and enrollment files. Using multivariate fixed effects regression, we found that following implementation of managed care, greater access occurred in county plans where assessments and treatment were performed by the same clinician, and where service authorizations were made more rapidly. Lower access occurred in county plans where treating clinicians authorized services themselves. Results confirm the significant effects of managed care processes on outcomes and highlight the importance of system capacity.     

Variation in Routine Psychiatric Workload: The Role of Financing Source,Managed Care Participation,and Mental Health Workforce Competition

This study was conducted to examine the association between psychiatrists' demographic characteristics, payment source, and managed care participation and psychiatrists' practice workload, and between the supply of other mental health providers in a psychiatrist's county of practice and psychiatrists' practice workload. Data from the 1996 American Psychiatric Association National Survey of Psychiatric Practice were merged with national countywide measures of mental health workforce and environmental data from the 1996 Area Resource File. In comparison to male psychiatrists, female psychiatrists treat fewer patients per week, provide less total hours of weekly patient care, and obtain fewer new monthly referrals. An increase in psychiatrists' managed care participation was associated with only minor increases in the number of patients per week, weekly time spent in clinical care, and number of new monthly referrals. The supply of other mental health providers was not associated with variation in practice workload. Once psychiatrists participate in managed care plans, an increase in their participation rate does not significantly expand clinical practice workload. The supply of other mental health providers was not significantly associated with variation in psychiatrists' workload, which suggests that substitution effects may not be evident with this aspect of psychiatric practice.     

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.     

Outcome Assessment of the Medicaid Managed Care Program in Harris County (Houston)

Nowadays, managed care has taken over the management of the Medicaid program in most states of the nation. The patients treated in the public sector managed care system are very vulnerable and at high risk. Thus, we decided to measure the impact of managed care in the public-sector population of Texas. To this end, we assessed the treatment outcome at the Harris County Psychiatric Center (HCPC). Our results showed that after the implementation of the Medicaid managed care program in Houston, the bed utilization at HCPC decreased by 32% and the readmission rate increased by 21%; concomitantly, the length of stay decreased from 15.6 days to 9.3 days. Additionally, African-American and Hispanic-American patients were more negatively affected than Caucasian patients. Undoubtedly, the implementation of the Medicaid managed care system in Texas has led to untoward effects in the quality of care provided to the most disadvantaged population of the state.     

A Publicly Managed Medicaid Substance Abuse Carve-Out: Effects on Spending and Utilization

In 1998, Michigan Medicaid "carved out" substance abuse treatment from its medical plans, transferring the management responsibility and substantial financial risk to 15 specialized local entities called coordinating agencies. All these agencies were either non-profit or publicly owned, unlike carve-out entities in many other states. By the second year of the risk-based carve-out (2000), Medicaid payments per eligible were 9.1% lower than in the last year before the carve-out (1998). Reductions were largely achieved by serving fewer clients, not by reducing payments per client. Agencies faced with revenue reductions or small increases were more likely to reduce treatment spending.     

Correlates of Family Burden Under Medicaid Managed Mental Health Care

This study examined predictors of family burden (assistance in daily living, supervision, and subjective concern) for family members of Medicaid recipients with severe mental illness in two regions of Virginia. In the Richmond area, mental health services were provided on a no-risk fee-for-service basis, while in Tidewater these services were provided through a risk-based capitated contract with a managed care organization. No differences in family burden were attributable to the risk-based payment system. Predictors of increased family burden were (a) more reported client symptoms and disruptive behaviors, (b) status as a parent, and (c) living with the client.     

Compliance with Mental Health and Other Specialty Care Referrals among Medicare/Medicaid Dual Enrollees

Objectives: To examine and compare non-compliance with mental health and other specialty referrals among low-income elderly.Methods: A survey of 2,128 community-dwelling elderly assessed mental health and other specialty referral in the past year and compliance with these referrals. Non-compliant participants and those who had encountered difficulties in arranging referral appointments were asked about the barriers.Results: 16.7% with mental health referrals vs. 4.8% with other specialty referrals did not comply (p < .001). The main reason for non-compliance with mental health referrals was lack of perceived need.Discussion: Lack of perceived need for professional help is a major barrier to specialty mental health care.     

Assessment of the Massachusetts Behavioral Health Program Year 6

After a difficult transition from the previous vendor to the Massachusetts Behavioral Health Partnership (MBHP), Year 6 was a year of stability and incremental changes for the Massachusetts Behavioral Health Program. This assessment of Year 6 is based on interviews with key players, data provided by the MBHP, a survey of providers, as well as on the fifth year of an ongoing review of the program. Results indicate that enrollment grew, and new services were developed in response to identified needs. Providers considered access, utilization, and quality of care to be the same or better than a year earlier. Coordination improved, but was not optimal. Clinical and overall decisions with MBHP were collaborative or negotiated and less hierarchical in manner than the previous year. Providers rated MBHP better than other managed care organizations on quality of care and utilization review decisions, access, flexibility, and administration.     

How Managed Care Has Affected Mental Health Case Management Activities, Caseloads, and Tenure

The purpose of this study was to identify changes in case management within public sector mental health, following the implementation of managed care. Case managers in the State of Oregon completed surveys in 1992 and 2000 regarding aspects of case management. Results showed that current case managers are more experienced and expect longer tenure than previously. Caseload sizes have increased. Meanwhile, case managers' activities and functions have not changed across time periods. The results suggest that mental health personnel have changed in the past decade, though the practice of case management has remained largely the same.     

Managed Behavioral Health Care:Lessons From Massachusetts

Since implementing the first statewide carve-out for behavioral health care in 1992, Massachusetts has achieved sustained reductions in cost, increases in access, and improvements in major quality measures. This introduction to a special issue describes the context, linkages with primary care, consumer satisfaction, unmet need, performance incentives (a key component of the success), stakeholder perspectives, and impacts on special populations. Donald S. Shepard, Ph.D., is a Professor, and Marilyn C. Daley, Ph.D., is a Senior Research Associate, both in the Heller School at Brandeis University. Richard H. Beinecke, D.P.A., A.C.S.W., is an Associate Professor in the Department of Public Management at Suffolk University. Clare L. Hurley is an Executive Assistant and candidate for an M.M. in the Heller School at Brandeis University. The first three authors are editors of this special issue. The conference on which this issue is based and the publication of this issue were supported by grant number R13AA14244-01 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to Brandeis University. Address for correspondence: Donald S. Shepard, Ph.D., Schneider Institute for Health Policy, Heller School, Mail Stop 035, Brandeis University, Waltham, MA 02454-9110. Fax: 781-736-3928. E-mail: shepard@brandeis.edu. Web: http://sihp.brandeis.edu/Shepard.     

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.