Mary C. Masland

Racial/Ethnic Minority Children’s Use of Psychiatric Emergency Care in California’s Public Mental Health System

OBJECTIVES We examined rates and intensity of crisis services use by race/ethnicity for 351,174 children younger than 18 years who received specialty mental health care from Californias 57 county public mental health systems between July 1998 and June 2001. METHODS We used fixed-effects regression for a controlled assessment of racial/ethnic disparities in childrens use of hospital-based services for the most serious mental health crises (crisis stabilization services) and community-based services for other crises (crisis intervention services). RESULTS African American children were more likely than were White children to use both kinds of crisis care and made more visits to hospital-based crisis stabilization services after initial use. Asian American/Pacific Islander and American Indian/Alaska Native children were more likely than were White children to use hospital-based crisis stabilization services but, along with Latino children, made fewer hospital-based crisis stabilization visits after an initial visit. CONCLUSIONS African American children used both kinds of crisis services more than did White children, and Asian Americans/Pacific Islander and American Indians/Alaska Native children visited only when they experienced the most disruptive and troubling kind of crises, and made nonrecurring visits.

Use of communication technologies to cost-effectively increase the availability of interpretation services in healthcare settings.

Poor patient-provider communication due to limited English proficiency (LEP) costs healthcare providers and payers through lower patient use of preventive care, misdiagnosis, increased testing, poor patient compliance, and increased hospital and emergency room admissions. Scarcity of bilingual healthcare professionals and prohibitive interpretation costs hinder full implementation of language service despite federal and state laws requiring their provision. We review recent published literature and unpublished data documenting the use of telephonic and video interpretation methodologies to improve healthcare communication with LEP persons. For example, a cooperative of nine California public hospitals and their associated community clinics, psychiatric facilities, skilled nursing facilities, and public health departments have implemented shared video interpretation services with video/voice-over Internet Protocol call center technology that automatically routes requests for interpretation in 15 languages to a pool of 30 full-time interpreters and 4 trained bilingual staff. For organizations seeking to initiate or expand their language services, the Internet provides access to translated documents, promising practices, step-by-step guides, planning tools, and research briefs. Such recent technological advances make provision of language services-to respond to federal and state mandates and improve access and quality of care to LEP persons-more feasible than is widely believed. Increased government and foundation support, and collaboration among provider organizations themselves can catalyze these efforts.

Ethnic Differences in Children's Entry into Public Mental Health Care via Emergency Mental Health Services.

For children and youth making a mental health crisis visit, we investigated ethnic disparities in whether the children and youth were currently in treatment or whether this crisis visit was an entry or reentry point into mental health treatment. We gathered Medicaid claims for mental health services provided to 20,110 public-sector clients ages 17 and younger and divided them into foster care and non-foster care subsamples. We then employed logistic regression to analyze our data with sociodemographic and clinical controls. Among children and youth who were not placed in foster care, African Americans, Latinos, and Asian Americans were significantly less likely than Caucasians to have received mental health care during the three months preceding a crisis visit. Disparities among children and youth in foster care were not statistically significant. Ethnic minority children and youth were more likely than Caucasians to use emergency care as an entry or reentry point into the mental health treatment, thereby exhibiting a crisis-oriented pattern of care.

Increasing California children's Medicaid-financed mental health treatment by vigorously implementing Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

Background: Children living in poverty—especially children living in rural areas and in areas lacking a commitment to providing mental health care—have considerable unmet need for mental health treatment. Expansion of Medicaids Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program might help to address this problem. Objective: To evaluate whether a legally compelled expansion of mental health screening, treatment, and financing under EPSDT would translate into higher Medicaid penetration rates. Our particular focus was on changes in rural treatment systems and systems historically receiving low levels of state funding (ie, “underequity” counties). Methods: We used fixed-effects regression methods by observing 53 California county mental health plans over 36 quarters, yielding 1908 observations. Our models controlled for all static, county, and service system characteristics, and for ongoing linear trends in penetration rates. Results: After controlling for previous trends, mental health treatment access increased following EPSDT mental health program expansion. The increase was greatest in rural systems, and counties that previously received less state funding which showed the greatest penetration rate increases. Conclusions: EPSDT mental health expansion and increased funding increased Medicaid-financed mental health treatment. The expansion efforts had the greatest effects in rural and underequity counties that faced the greatest barriers to mental health service use.

Effects on Outpatient and Emergency Mental Health Care of Strict Medicaid Early Periodic Screening, Diagnosis, and Treatment Enforcement

We investigated enforcement of mental health benefits provided by California Medicaids Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Enforcement, compelled by a consumer-driven lawsuit, resulted in an almost 4-fold funding increase over a 5-year period. We evaluated the impact of enforcement on outpatient treatment intensity (number of visits per child) and rates of emergency care treatment. Using fixed-effects regression, we examined the number of outpatient mental health visits per client and the percentage of all clients using crisis care across 53 autonomous California county mental health plans over 32 three-month periods (quarters; emergency crisis care rates) and 36 quarters (out-patient mental health visits). Enforcement of EPSDT benefits in accordance with federal law produced favorable changes in patterns of mental health service use, consistent with policy aims.

Managed care in the public mental health system.

The movement towards managed care in the public mental health system has surpassed efforts to develop a systematic literature concerning its theory, practice, and outcome. In particular little has been written about potential challenges and difficulties in translating managed care systems from their origins in the private sector to the delivery of public sector mental health services. This paper provides an overview of managed care definitions, organizational arrangements, administrative techniques, and roles and responsibilities using a theoretical framework adopted from economics referred to as principal-agent theory. Consistent with this theory, we assert that the primary function of the managed care organization is to act as agent for the payor and to manage the relationships between payors, providers, and consumers. From this perspective, managed care organizations in the public mental health system will be forced to manage an extremely complex set of relationships between multiple government payors, communities, mental health providers, and consumers. In each relationship, we have identified many challenges for managed care including the complexity of public financing, the vulnerable nature of the population served, and the importance of synchronization between managed care performance and community expectations for the public mental health system. In our view, policy regarding the role of managed care in the public mental health system must evolve from an understanding of the dynamics of government-community-provider-consumer “agency relationships.”

The political development of “Program Realignment”: California’s 1991 mental health care reform

This article reviews the legislative process that resulted in the most significant reform of California’s public mental health system in nearly 25 years. The reform, termed “Program Realignment”, decentralized administrative and fiscal control of the mental health system from the state to the county level. The system prior to Program Realignment is discussed here to reveal an already diverse and decentralized county mental health system, fiscal distress, and general dissatisfaction with the system. From these conditions, the objectives of the relevant political actors arose. By tracing the policy development process of Program Realignment, several independent variables are revealed that help explain how and why this legislation came into being and allow generalization of this case to other states’ experiences. These independent variables are an urgent need for action within a limited time frame, a preexisting knowledge base and well-developed policy networks, a spirit of bipartisan cooperation, and the presence of strong leadership. Preliminary evidence suggests that consolidation of fiscal and programmatic authority at the local level has reduced fragmentation of services and increased fiscal flexibility. However, there is concern that the quality of care offered by the state’s 59 local mental health programs will become increasingly disparate and that increased financial flexibility may not be used to improve services for clients but to save money for local governments. Lessons from California’s experience can alert other states to the pros and cons of this policy approach to providing mental health services and inform policymakers in other states of the steps involved in bringing about such a policy change.This article reviews the legislative process that resulted in the most significant reform of California’s public mental health system in nearly 25 years. The reform, termed “Program Realignment”, decentralized administrative and fiscal control of the mental health system from the state to the county level. The system prior to Program Realignment is discussed here to reveal an already diverse and decentralized county mental health system, fiscal distress, and general dissatisfaction with the system. From these conditions, the objectives of the relevant political actors arose. By tracing the policy development process of Program Realignment, several independent variables are revealed that help explain how and why this legislation came into being and allow generalization of this case to other states’ experiences. These independent variables are an urgent need for action within a limited time frame, a preexisting knowledge base and well-developed policy networks, a spirit of bipartisan cooperation, and the presence of strong leadership. Preliminary evidence suggests that consolidation of fiscal and programmatic authority at the local level has reduced fragmentation of services and increased fiscal flexibility. However, there is concern that the quality of care offered by the state’s 59 local mental health programs will become increasingly disparate and that increased financial flexibility may not be used to improve services for clients but to save money for local governments. Lessons from California’s experience can alert other states to the pros and cons of this policy approach to providing mental health services and inform policymakers in other states of the steps involved in bringing about such a policy change.

The effects of financial and administrative decentralization of public mental health services in california: Preliminary findings (summary)

This preliminary report illustrates the social and financial benefits of decentralization of public mental health services. Increased local financial risk and flexibility have resulted in greater use of less costly local outpattent mental health services, which are less restrictive and empirically more therapeutic.