Neal Wallace

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.

Mental Health Costs and Access Under Alternative Capitation Systems in Colorado

OBJECTIVE To examine service cost and access for persons with severe mental illness under Medicaid mental health capitation payment in Colorado. Capitation contracts were made with two organizational models: community mental health centers (CMHCs) that manage and deliver services (direct capitation [DC]) and joint ventures between CMHCs and a for-profit managed care firm (managed behavioral health organization, [MBHO]) and compared to fee for service (F.F.S.). DATA SOURCES/STUDY SETTING Both primary and secondary data were collected for the year prior to the new financing policy and the following two years (1995-1998). STUDY DESIGN A stratified random sample of 522 severely mentally ill subjects was selected from comparable geographic areas within the capitated and FFS regions of Colorado. Major variables include service cost, utilization, and access (probability of service use) derived from secondary claims data, subject reported access collected at six-month intervals, and baseline outcomes (symptoms, functioning, and quality of life). PRINCIPAL FINDINGS In comparison to the FFS area, cost per person was reduced in the capitated areas in each of the two years following implementation. By the end of year two, cost per person was reduced by two-thirds in the MBHO areas and by one-fifth in the DC areas. Reductions in access were found for both capitated areas, although reductions in utilization for those receiving service were found only in the MBHO model. CONCLUSIONS Medicaid mental health capitation in Colorado resulted in cost reducing service changes for persons with severe mental illness. Assessment of outcome change is necessary to identify cost effectiveness.

Mental health costs and outcomes under alternative capitation systems in Colorado: early results

BACKGROUND: This study presents preliminary findings for the first nine months of the State of Colorado USA Medicaid capitation Pilot Project. Two different models of capitation (model I and model II) are compared with fee for service (FFS) in providing services to severely and persistently mentally ill adults. In model I the states mental health authority contracts with community mental health centers (CMHCs) who both manage the care and deliver mental health services, while in model II the state contracted with a joint venture between a for-profit managed care firm who manage the care with either a single CMHC or an alliance of CMHCs who deliver the mental health services. AIMS: Our objective is to examine utilization, cost and outcomes of inpatient and outpatient (including community based) services before and after the implementation of a capitated payment system for Colorados Medicaid mental health services compared to services that remained under FFS reimbursement. METHODS: The stratified, random sample includes 513 consumers (188 for model I, 179 for model II, and 146 for FFS). Consumer outcomes were collected by trained interviewers and include 17 measures of symptoms, health status, functioning, quality of life and consumer satisfaction. Utilization and cost of services are from the Medicaid claims data and a shadow billing data system (post-capitation) designed by Colorado. The first step of the two-step regression procedure adjusts for the presence of individuals with use or no service use during the specified time while the second step, ordinary least-squares regression, is applied to the sample who utilized services. RESULTS: These preliminary findings indicate consistent reductions in inpatient user costs and probability of outpatient use under capitation. Combining all services, there are consistent reductions in the probability of use in both models: model I had significantly higher initial probability of use for any service. Only model II showed a statistically significant decrease in post-capitation overall user costs, but they were initially higher than model I or FFS. Estimated total cost per person for model I suggests virtually no change from the pre- to post-capitation period. Model II had the highest pre-capitation and the lowest post-capitation estimated cost per person. Examination of pre measures of outcomes across capitated areas suggest that samples drawn from the FFS, model I and model II areas were comparable in severity of psychiatric symptoms, functioning, health status and quality of life. No changes were found in outcomes. DISCUSSION: These early findings are consistent with the limited literature on capitation. Both studies of capitation integrated with medical care and those specific to mental health settings did not find adverse changes in outcomes compared to FFS. Limitations include the short follow-up period, lack of detail and possible under-reporting of outpatient services provided by the shadow billing data system. CONCLUSIONS: For the short term, it is concluded that capitation can reduce service cost per person without significant change in clinical status. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Implications are unclear until we can determine whether (i) reductions in the numbers receiving service indicates favorable consumer outcomes or reductions in access and (ii) lack of change in consumer outcomes is due to the benefits of capitation or the lack of sensitivity of the outcome measures. IMPLICATIONS FOR HEALTH CARE POLICY FORMULATION: Implications are premature for these early findings. IMPLICATIONS FOR FUTURE RESEARCH: Future research should include longer follow-up as well as analysis of long-term consequences for both cost savings and clinical outcomes.

The Individual and Program Impacts of Eliminating Medicaid Dental Benefits in the Oregon Health Plan

OBJECTIVES We determined how elimination of dental benefits among adult Medicaid beneficiaries in Oregon affected their access to dental care, Medicaid expenditures, and use of medical settings for dental services. METHODS We used a natural experimental design using Medicaid claims data (n = 22 833) before and after Medicaid dental benefits were eliminated in Oregon in 2003 and survey data for continuously enrolled Oregon Health Plan enrollees (n = 718) covering 3 years after benefit cuts. RESULTS Claims analysis showed that, compared with enrollees who retained dental benefits, those who lost benefits had large increases in dental-related emergency department use (101.7%; P < .001) and expenditures (98.8%; P < .001) and in all ambulatory medical care use (77.0%; P < .01) and expenditures (114.5%; P < .01). Survey results indicated that enrollees who lost dental benefits had nearly 3 times the odds (odds ratio = 2.863; P = .001) of unmet dental need, and only one third the odds (odds ratio = 0.340; P = .001) of getting annual dental checkups relative to those retaining benefits. CONCLUSIONS Combined evidence from both analyses suggested that the elimination of dental benefits resulted in significant unmet dental health care needs, which led to increased use of medical settings for dental problems.

Two-Year Outcomes of Fee-for-Service and Capitated Medicaid Programs for People with Severe Mental Illness

OBJECTIVE To examine the effects of two models of capitation on the clinical outcomes of Medicaid beneficiaries in the state of Colorado. DATA SOURCE A large sample of adult, Medicaid beneficiaries with severe mental illness drawn from regions where capitation contracts were (1) awarded to local community mental health agencies (direct capitation), (2) awarded to a joint venture between local community mental health agencies and a large, private managed behavioral health organization, and (3) not awarded and care continued to be reimbursed on a fee-for-service basis. STUDY DESIGN The three samples were compared on treatment outcomes assessed over 2 years (total n = 591). DATA COLLECTION METHODS Study participants were interviewed by trained, clinical interviewers using a standardized protocol consisting of the GAF, BPRS, QOLI, and CAGE. PRINCIPAL FINDINGS Outcomes were comparable across most outcome measures. When outcome diffrences were evident, they tended to favor the capitation samples. CONCLUSIONS Medicaid capitation in Colorado does not appear to have negatively affected the outcomes of people with severe mental illness during the first 2 years of the program. Furthermore, the type of capitation model was unrelated to outcomes in this study.

Social Networks and Their Relationship to Mental Health Service Use and Expenditures Among Medicaid Beneficiaries

OBJECTIVE This study examined the relationship between social networks and mental health services utilization and expenditures. METHODS A sample of 522 Medicaid mental health consumers was randomly selected from the administrative records of Colorados Department of Health Care Policy and Financing. The administrative records contain information on utilization of services and expenditures of Medicaid beneficiaries within Colorados Mental Health Services. In addition to the administrative records, social network and psychosocial data were gathered through longitudinal survey interviews. The interviews were conducted at six-month intervals between 1994 and 1997. Measures used in the regression analysis included demographic characteristics, clinical diagnoses, the social network index, expenditures, and utilization variables. RESULTS The social network index was positively associated with utilization of and expenditures for inpatient services in local hospitals but negatively associated with expenditures for inpatient services in state hospitals or outpatient services. Relationships with family were negatively related to expenditures for outpatient services. Relationships with friends were positively associated with utilization of and expenditures for psychiatric inpatient services in local hospitals. CONCLUSIONS Consumers who had higher social network index scores utilized more inpatient psychiatric services in local hospitals and had higher expenditures than those who had lower scores. Consumers who had higher social network index scores also had lower expenditures for inpatient services in state hospitals and outpatient services than those who have lower scores. Findings suggest that social network is associated with mental health utilization and expenditures in various ways, associations that need to be researched further.

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.

Capitation of Public Mental Health Services in Colorado: A Five-Year Follow-Up of System-Level Effects

OBJECTIVE Capitated Medicaid mental health programs have reduced costs over the short term by lowering the utilization of high-cost inpatient services. This study examined the five-year effects of capitated financing in community mental health centers (CMHCs) by comparing not-for-profit with for-profit programs. METHODS Data were from the Medicaid billing system in Colorado for the precapitation year (1994) and a shadow billing system for the postcapitation years (1995-1999). In a panel design, a random-effect approach estimated the impact of two financing systems on service utilization and cost while adjusting for all the covariates. RESULTS Consistent with predictions, in both the for-profit and the not-for-profit CMHCs, relative to the precapitation year, there were significant reductions in each postcapitation year in high-cost treatments (inpatient treatment) for all but one comparison (not-for-profit CMHCs in 1999). Also consistent with predictions, the for-profit programs realized significant reductions in cost per user for both outpatient services and total services. In the not-for-profit programs, there were no significant changes in cost per user for total services; a significant reduction in cost per user for outpatient services was found only in the first two years, 1995 and 1996). CONCLUSIONS The evidence suggests that different strategies were used by the not-for-profit and for-profit programs to control expenditures and utilization and that the for-profit programs were more successful in reducing cost per user.