Preventive mental health and substance abuse programs and services in managed care

If effective preventive behavioral health services were available to the millions of Americans enrolled in managed care organizations, the public health impact could be significant. This project sought to summarize published research-based information about effective preventive interventions for mental health and substance use (tobacco, alcohol, and other drugs) shown or likely to have no negative cost impact. Fifty-four studies satisfied seven screening criteria. Their findings demonstrated that preventive behavioral health interventions appropriate for managed care settings have been evaluated and have been shown to be effective. Some produced cost savings or offset costs. Six preventive behavioral health interventions are therefore recommended for managed care.     

Establishing a capitation policy for mental health and substance abuse services in healthcare reform

In healthcare reform the evolution toward capitated payment systems raises many questions that are unique to behavioral healthcare providers. These issues include how to structure risk contracts, how to set appropriate prices and how to price and cover the severely mentally ill and uninsured. Two possible solutions to the pricing dilemma are described in this article: using prior-use experience for setting prices, with a DRG-type classification formula, and using a combination of past-use formulas and current utilization data.     

Managed care and access to substance abuse treatment services

Using nationally representative data from 1995 and 2000, this study examined how managed care penetration and other organizational characteristics were related to accessibility to outpatient substance abuse treatment. At an organizational level, access was measured as the percentage of clients unable to pay for services; the percentage of clients receiving a reduced fee; and the percentage of clients with shortened treatment because of their inability to pay. Treatment units with both relatively low and relatively high managed care penetration were more likely to support access to care; these units provided care to higher percentages of clients unable to pay and were less likely to shorten treatment because of client inability to pay. Treatment units with midrange managed care penetration were least likely to support access to care. The complexity of managing in an environment of conflicting incentives may reduce the organization's ability to serve those with limited financial means.     

Mental health services and outcome-driven health care.

Mental disorders and mental symptoms often go untreated in both chronic care and primary care settings. However, they covary with functional disability. They are likely to impair social and occupational function in medical outpatients and to cause excess instrumental and cognitive disability in frail older persons. In both groups, they are frequent and often remediable. The costs of untreated mental disorders are often shifted to caregivers and to society in general. To ensure adequate mental health care requires a reorientation of medical care toward optimizing function and well-being as well as longevity. Such a reorientation will necessarily entail more attention to treatable mental disorders. Research is needed to (1) develop firm knowledge on which to base integrated medical and mental health treatment and (2) evaluate the potential economic benefits of combined care. Incentives must be changed if such a paradigm of care is to prosper.     

Low-income women's use of substance abuse and mental health services

This paper examines the utilization of mental health, alcohol, and drug treatment in a sample of low-income women. We analyze data from the Women's Employments Study, a study examining the barriers to employment for welfare recipients, and compare prevalence rates of mental health disorders and service utilization with the National Comorbidity Survey. Fewer than one in five of the respondents with a current mental health and/or substance dependence problem in the Women's Employment Study (WES) received treatment in the past 12 months. A logistic regression model of the association among demographic variables, risk factors, and service utilization in the WES found that having a co-occurring substance dependence and mental health disorder was significantly associated with receiving treatment. Those respondents with an increased number of barriers were significantly less likely to receive treatment. The authors argue that the success of welfare reform may hinge on low-income women's access to and utilization of appropriate services.     

Public sector managed care for substance abuse treatment: Opportunities for health services research

Observations of reduced utilization of alcohol and drug abuse treatment following the introduction of managed behavioral health care suggest that substance abuse services may be especially responsive to managed care restrictions and limits. In publicly funded treatment systems, patient attributes, system and provider characteristics, and financing mechanisms may heighten susceptibility to unintended effects. The State Substance Abuse and Mental Health Treatment Managed Care Evaluation Program reviewed state managed care programs for publicly funded alcohol and drug treatment services and is evaluating programs in Arizona, Iowa, Maryland, and Nebraska. The article describes initiatives and outlines evaluation activities. It discusses the opportunities and challenges of assessing public managed care plans.     

Welfare reform and substance abuse

The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) changed the nature, purpose, and financing of public aid. Researchers, administrators, and policymakers expressed special concern about the act's impact on low-income mothers with substance use disorders. Before PRWORA's passage, however, little was known about the true prevalence of these disorders among welfare recipients or about the likely effectiveness of substance abuse treatment interventions for welfare recipients. Subsequent research documented that substance abuse disorders are less widespread among welfare recipients than was originally thought and are less common than other serious barriers to self-sufficiency. This research also showed significant administrative barriers to the screening, assessment, and referral of drug-dependent welfare recipients. This article summarizes current research findings and examines implications for welfare reform reauthorization.     

Comparing the Canadian and US systems of health care in an era of health care reform

The purpose of this article is to provide an informed comparison of health care in the United States and Canada along multiple dimensions. Specifically this article looks at coverage, access, cost, health outcomes, satisfaction, and underlying ideology. Canada fares better than the United States with regard to coverage, cost, and health outcomes. While overall access is better in Canada, patients are sometimes required to endure longer wait times than in the United States. Reports of satisfaction levels vary across studies, but most evidence points toward comparable levels of satisfaction in Canada and the United States. Strong ideological differences underlie the Canadian and American systems, making the acceptance and implementation of certain reforms difficult. The potential impact of the US Patient Protection and Affordable Care Act (PPACA), as well as recent Canadian health care reforms on coverage, access, cost, and health outcomes are also discussed.     

The impact of managed care on substance abuse treatment services

OBJECTIVE: To examine the impact of managed care on the number and types of services offered by substance abuse treatment (SAT) facilities. Both the number and types of services offered are important factors to analyze, as research shows that a broad range of services increases treatment effectiveness. DATA SOURCES: The 2000 National Survey of Substance Abuse Treatment Services (NSSATS), which is designed to collect data on service offerings and other characteristics of SAT facilities in the United States. These data are merged with data from the 2002 Area Resource File (ARF), a county-specific database containing information on population and managed care activity. We use data on 10,513 facilities, virtually a census of all SAT facilities. STUDY DESIGN: We estimate the impact of managed care (MC) on the number and types of services offered by SAT facilities using instrumental variables (IV) techniques that account for possible endogeneity between facilities' involvement in MC and service offerings. Due to limitations of the NSSATS data, MC and specific services are modeled as binary variables. PRINCIPAL FINDINGS: We find that managed care causes SAT facilities to offer, on average, approximately two fewer services. This effect is concentrated primarily in medical testing services (i.e., tests for TB, HIV/AIDs, and STDs). We also find that MC increases the likelihood of offering substance abuse assessment and relapse prevention groups, but decreases the likelihood of offering outcome follow-up. CONCLUSION: Our findings raise policy concerns that managed care may reduce treatment effectiveness by limiting the range of services offered to meet patient needs. Further, reduced onsite medical testing may contribute to the spread of infectious diseases that pose important public health concerns.     

Mental health care roles of non-medical primary health and social care services

Changes in patterns of delivery of mental health care over several decades are putting pressure on primary health and social care services to increase their involvement. Mental health policy in countries like the UK, Australia and New Zealand recognises the need for these services to make a greater contribution and calls for increased intersectoral collaboration. In Australia, most investment to date has focused on the development and integration of specialist mental health services and primary medical care, and evaluation research suggests some progress. Substantial inadequacies remain, however, in the comprehensiveness and continuity of care received by people affected by mental health problems, particularly in relation to social and psychosocial interventions. Very little research has examined the nature of the roles that non-medical primary health and social care services actually or potentially play in mental health care. Lack of information about these roles could have inhibited development of service improvement initiatives targeting these services. The present paper reports the results of an exploratory study that examined the mental health care roles of 41 diverse non-medical primary health and social care services in the state of Victoria, Australia. Data were collected in 2004 using a purposive sampling strategy. A novel method of surveying providers was employed whereby respondents within each agency worked as a group to complete a structured survey that collected quantitative and qualitative data simultaneously. This paper reports results of quantitative analyses including a tentative principal components analysis that examined the structure of roles. Non-medical primary health and social care services are currently performing a wide variety of mental health care roles and they aspire to increase their involvement in this work. However, these providers do not favour approaches involving selective targeting of clients with mental disorders.     

Parity for mental health and substance abuse care under managed care

BACKGROUND: Parity in insurance coverage for mental health and substance abuse has been a key goal of mental health and substance abuse care advocates in the United States during most of the past 20 years. The push for parity began during the era of indemnity insurance and fee for service payment when benefit design was the main rationing device in health care. The central economic argument for enacting legislation aimed at regulating the insurance benefit was to address market failure stemming from adverse selection. The case against parity was based on inefficiency related to moral hazard. Empirical analyses provided evidence that ambulatory mental health services were considerably more responsive to the terms of insurance than were ambulatory medical services. AIMS: Our goal in this research is to reexamine the economics of parity in the light of recent changes in the delivery of health care in the United States. Specifically managed care has fundamentally altered the way in which health services are rationed. Benefit design is now only one mechanism among many that are used to allocate health care resources and control costs. We examine the implication of these changes for policies aimed at achieving parity in insurance coverage. METHOD: We develop a theoretical approach to characterizing rationing under managed care. We then analyze the traditional efficiency concerns in insurance, adverse selection and moral hazard in the context of policy aimed at regulating health and mental health benefits under private insurance. RESULTS: We show that since managed care controls costs and utilization in new ways parity in benefit design no longer implies equal access to and quality of mental health and substance abuse care. Because costs are controlled by management under managed care and not primarily by out of pocket prices paid by consumers, demand response recedes as an efficiency argument against parity. At the same time parity in benefit design may accomplish less with respect to providing a remedy to problems related to adverse selection.     

Mental health patients in primary health care services in Nepal

Patients attending two primary care settings in Nepal (a village health post and a district hospital outpatient department) were screened for psychiatric morbidity using the Self Reporting Questionnaire. Approximately one-quarter of all patients screened were found to have psychiatric morbidity. Women presenting were found to have higher frequency of "psychiatric caseness" than men. All these psychiatric patients presented with physical complaints, none with psychological, and the most common physical symptoms presented were abdominal pain, headache and cough. Health worker recognition of these cases was 29% in the health post and 0% in the hospital. Conclusions are drawn regarding the need for sufficient and relevant psychiatric teaching in health worker curriculae.