David Mancuso

Evaluation of the Washington State Screening, Brief Intervention, and Referral to Treatment Project: Cost Outcomes for Medicaid Patients Screened in Hospital Emergency Departments

Background:Substance abuse is a major determinant of morbidity, mortality, and health care resource consumption. We evaluated a screening, brief intervention, and referral to treatment (SBIRT) program, implemented in 9 hospital emergency departments (ED) in Washington State. Methods:Working-age, disabled Medicaid patients who were screened and received a brief intervention (BI) from April 12, 2004 through September 30, 2006 were included in the studys intervention group (N = 1557). The comparison group (N = 1557), constructed using (one-to-one) propensity score matching, consisted of Medicaid patients who received care in one of the counties in which an intervention hospital ED was located but who did not receive a BI. We estimated difference-in-difference (DiD) regression models to assess the effects of the SBIRT program for different patient groups. Results:The SBIRT program was associated with an estimated reduction in Medicaid costs per member per month of

Effect of co-occurring disorders and intimate partner violence on substance abuse treatment outcomes

366 (P = 0.05) for all patients, including patients who received a referral for chemical dependency (CD) treatment. For patients who received a BI only and had no CD treatment in the year before or the year after the ED visit, the estimated reduction in Medicaid per member per month costs was

Care Coordination Program For Washington State Medicaid Enrollees Reduced Inpatient Hospital Costs

542 (P = 0.06). The SBIRT program was also associated with decreased inpatient utilization (P = 0.04). Conclusion:SBIRT programs have potential to limit resource consumption among working-age, disabled Medicaid patients. The hospital ED seems especially well suited for SBIRT programs given the large number of injured patients treated in the ED and the fact that many conditions treated are related to substance abuse.

A randomized controlled trial of intensive care management for disabled Medicaid beneficiaries with high health care costs.

This retrospective cohort study examined risk factors for co-occurring substance use and mental disorders (COD) and the effect of COD and intimate partner violence (IPV) victimization among women and IPV-related arrest among men on 1-year substance abuse treatment outcomes. The study sample included clients admitted to Washington State publicly funded substance abuse treatment facilities in 2004-2007. COD was associated with a high substance use and IPV risk profile at admission. Having a COD decreased the odds of completing treatment by 30% among men and women and increased the risk of treatment reentry by 9% and 12% among men and women, respectively. IPV also decreased the odds of completing treatment among women and increased the risk of treatment reentry among men. Men with COD were less likely than those without COD to be arrested for substance-related crimes but more likely to be arrested for violence-related crimes in the follow-up period. Implications of these findings are discussed.

Childhood adversity and behavioral health outcomes for youth: an investigation using state administrative data

Managing clinically complex populations poses a major challenge for state agencies trying to control health care costs and improve quality of care for Medicaid beneficiaries. In Washington State a care coordination intervention, the Chronic Care Management program, was implemented for clinically complex Medicaid beneficiaries who met risk criteria defined by a predictive modeling algorithm. We used propensity score matching to evaluate the programs impact on health care spending and utilization and mortality. We found large and significant reductions in inpatient hospital costs (

Case Studies From Three States: Breaking Down Silos Between Health Care And Criminal Justice

318 per member per month) among patients who used the program. The estimated reduction in overall medical costs of

Evaluation of an Innovative Medicaid Health Policy Initiative to Expand Substance Abuse Treatment in Washington State

248 per member per month exceeded the cost of the intervention but did not reach statistical significance. These results suggest that well-designed targeted care coordination services could reduce health care spending for Medicaid beneficiaries with complex health care needs.

Evaluation of the Medicaid Buy-In Program in Washington State Outcomes for Workers With Disabilities Who Purchase Medicaid Coverage

OBJECTIVE To evaluate outcomes of a registered nurse-led care management intervention for disabled Medicaid beneficiaries with high health care costs. DATA SOURCES/STUDY SETTING Washington State Department of Social and Health Services Client Outcomes Database, 2008-2011. STUDY DESIGN In a randomized controlled trial with intent-to-treat analysis, outcomes were compared for the intervention (n = 557) and control groups (n = 563). A quasi-experimental subanalysis compared outcomes for program participants (n = 251) and propensity score-matched controls (n = 251). DATA COLLECTION/EXTRACTION METHODS Administrative data were linked to describe costs and use of health services, criminal activity, homelessness, and death. PRINCIPAL FINDINGS In the intent-to-treat analysis, the intervention group had higher odds of outpatient mental health service use and higher prescription drug costs than controls in the postperiod. In the subanalysis, participants had fewer unplanned hospital admissions and lower associated costs; higher prescription drug costs; higher odds of long-term care service use; higher drug/alcohol treatment costs; and lower odds of homelessness. CONCLUSIONS We found no health care cost savings for disabled Medicaid beneficiaries randomized to intensive care management. Among participants, care management may have the potential to increase access to needed care, slow growth in the number and therefore cost of unplanned hospitalizations, and prevent homelessness. These findings apply to start-up care management programs targeted at high-cost, high-risk Medicaid populations.

The Effect of Substance Abuse Treatment on Medicaid Expenditures among General Assistance Welfare Clients in Washington State

This study aimed to measure the relative contribution of adverse experiences to adolescent behavioral health problems using administrative data. Specifically, we sought to understand the predictive value of adverse experiences on the presence of mental health and substance abuse problems for youth receiving publicly funded social and health services. Medicaid claims and other service records were analyzed for 125,123 youth age 12-17 and their biological parents. Measures from administrative records reflected presence of parental domestic violence, mental illness, substance abuse, criminal justice involvement, child abuse and/or neglect, homelessness, and death of a biological parent. Mental health and substance abuse status of adolescents were analyzed as functions of adverse experiences and other youth characteristics using logistic regression. In multivariate analyses, all predictors except parental domestic violence were statistically significant for substance abuse; parental death, parental mental illness, child abuse or neglect and homelessness were statistically significant for mental illness. Odds ratios for child abuse/neglect were particularly high in both models. The ability to identify risks during childhood using administrative data suggests the potential to target prevention and early intervention efforts for children with specific family risk factors who are at increased risk for developing behavioral health problems during adolescence. This study illustrates the utility of administrative data in understanding adverse experiences on children and the advantages and disadvantages of this approach.

Impact of sexual orientation and co-occurring disorders on chemical dependency treatment outcomes

The jail-involved population-people with a history of arrest in the previous year-has high rates of illness, which leads to high costs for society. A significant percentage of jail-involved people are estimated to become newly eligible for coverage through the Affordable Care Acts expansion of Medicaid, including coverage of substance abuse treatment and mental health care. In this article we explore the need to break down the current policy silos between health care and criminal justice, to benefit both sectors and reduce unnecessary costs resulting from lack of coordination. To draw attention to the hidden costs of the current system, we review three case studies, from Washington State, Los Angeles County in California, and New York City. Each case study addresses different aspects of care needed by or provided to the jail-involved population, including mental health and substance abuse, emergency care, and coordination of care transitions. Ultimately, bending the cost curve for health care and criminal justice will require greater integration of the two systems.