Paul G. Stiles

Medicaid Enrollment and Mental Health Service Use Following Release of Jail Detainees With Severe Mental Illness

OBJECTIVE This study assessed the extent to which Medicaid enrollment increased access to and use of services by persons with severe mental illness after their release from jail. METHODS A prospective cohort design was used that linked administrative data from several agencies in two large urban areas: King County (Seattle) from 1996 to 1998 and Pinellas County (Clearwater and St. Petersburg), Florida, from 1998 to 2000. Access to and use of community mental health services within 90 days after release from jail was examined, depending on whether persons were enrolled in Medicaid at the time of their release. All analyses were based on detentions, rather than unique persons. The effects of Medicaid status (enrolled or not enrolled) on four dependent variables (probability of use, days to first service, number of services used, and rate of service use) were estimated separately for each county. RESULTS A total of 1,210 persons who had 2,878 detentions were identified in Pinellas County: 2,215 of these detentions represented persons with Medicaid and 663 represented those without Medicaid. For King County, the corresponding numbers were 1,816 persons and 4,482 detentions: 2,752 of these detentions represented persons with Medicaid and 1,730 represented those without Medicaid. In both counties, those who had Medicaid at the time of their release were more likely to use services (p < .001), accessed community services more quickly (p < .001), and received more days of services (p < .001) than those without Medicaid. CONCLUSIONS Medicaid enrollment enhanced receipt of community services after jail release in these two large urban counties. These are the best currently available data, and the data suggest that efforts to enroll persons with severe mental illness in Medicaid and ensure enrollment upon jail release will improve their access to and receipt of community-based services after release.

Adherence to practice guidelines, clinical outcomes, and costs among Medicaid enrollees with severe mental illnesses.

The treatment of Medicaid enrollees diagnosed with depression or schizophrenia was examined to determine whether adherence to treatment guideline was associated with health care financing strategy, clinical outcomes, and cost-effectiveness. Individuals in a fee-for-service condition were significantly more likely to receive treatment consistent with guidelines than those in managed care. Mental health costs were higher for individuals diagnosed with schizophrenia, individuals in an acute phase of illness at intake into the study, and those receiving treatment consistent with practice guidelines. Being in an acute phase of illness and having treatment that comported with recommended practice guidelines were associated with higher total social costs. Policy implications of the findings and recommendations for future research are discussed.

Service penetration by persons with severe mental illness: How should it be measured?

As performance indicators and outcomes measures become essential parts of doing business, providers of mental health services are developing and using a number of access measures. One that is being used with increasing frequency is service penetration. However, the lack of standard methods for calculating and reporting service penetration has made the comparison of penetration rates across studies difficult. This article discusses the conceptualization and operationalization of service penetration. In addition, it presents an exploratory study of service penetration using data from the same persons using very different data sources; these data were collected during an evaluation of a Medicaid managed care system in Florida. The article offers recommendations for the use and reporting of service penetration rates.

Children's use of mental health services in different Medicaid insurance plans.

This study examined the effect of different Medicaid insurance plans on childrens mental health service use through survey, claims, and encounter data collected between February 1998 and February 1999. Participants were assigned to 1 of 3 insurance plans: fee-for-service, a Health Maintenance Organization and prepaid carve-out. Logistic and stratified logistic regression were used to examine the effect of plan on service utilization, adjusting for caregiver report of need for services and psychosocial functioning. There was no difference in service use by plan controlling for demographic characteristics; however, when psychopathology and caregiver report of need for services were included in the model, the odds of using services in the Health Maintenance Organization was half of and the odds in the carve-out 29% less than the odds of using services in fee-for-service. Characteristics of the interaction between need, psychopathology, and insurance plan that may be associated with the reduction in service use are discussed.

Formal Assessment of Voluntariness With a Three-Part Consent Process

Informed consent that is voluntary and made by an individual who is knowledgeable and competent is a foundational requirement for protecting human subjects from harm and exploitation that could result from research participation. In 1974 Miller and Willner proposed a two-part consent process that involved disclosure of information and assessment of comprehension. The authors propose a brief third component to the consent process: assessment of voluntariness. Three steps are involved: generate a list of potential coercive influences on the basis of the research population and the study context, develop a set of questions to assess the presence and intensity of the impact of these influences, and identify alternative courses of action should coercion be identified.

Ethically Using Administrative Data in Research Medicaid Administrators’ Current Practices and Best Practice Recommendations

Ethical standards and issues associated with the access and use of state Medicaid administrative data for research purposes from the data owners’ perspective (i.e., state Medicaid authorities) were examined. Key informants at Medicaid authorities were surveyed regarding their states’ policies and procedures related to the access and use of Medicaid data for research purposes. Results indicate that although a majority of states permit the use of Medicaid data by independent investigators for research purposes (74%), there is substantial variability across states in both the frequency with which access is granted as well as with the policies and procedures governing the access to these data. Literature on existing “best practices” by data owners regarding the use of administrative data in research is combined with survey findings to add the discussion in this highly important area and proposed guiding principles for administrative data owners and custodians are offered.

Poor and Depressed, The Tip of the Iceberg: The Unmet Needs of Enrollees in an Indigent Health Care Plan

Depression is a leading cause of disability [World Health Organization (WHO), 2001] with economic costs exceeding

Evaluation of a Summer Research Institute in Behavioral Health for Undergraduate Students

63 billion per year in the US [U.S. Department of Health and Human Services (DHHS), 1999]. The challenges of treating depression among the poor are compounded by broader social needs. This study examined the prevalence of depression and psychosocial needs among enrollees in an indigent health care plan. Results indicated clinical levels of depression were present in 28.6% of respondents (n=1,405). Depressed respondents were significantly more likely (p<0.001) to have co-occurring alcohol (OR=1.78; CI95=1.32–2.40), drug (OR=2.67; CI95=1.80–3.98), and health (OR=5.44; CI95 = 4.12–7.19) problems compared to non-depressed respondents. Significantly more social needs were also associated with depression. Depressed respondents averaged 7.8 needs compared to 3.6 among non-depressed respondents. Needs included a significantly increased likelihood (p<0.001) of lacking sufficient food (OR=2.56; CI95=1.97–3.34), shelter (OR=3.67; CI95=2.23–6.05), or money (OR=3.18; CI95= 2.39–4.23) and having more legal (OR=2.95; CI95=2.22–3.92) and family (OR=3.00; CI95=2.32–3.86) problems. The high rates of co-occurring social needs among individuals with clinical depression underscores the need for comprehensive, coordinated care in order to improve their quality of life and also reduce high utilization of crisis management services.

For-Profit Versus Non-Profit Freestanding Psychiatric Inpatient Facilities: An Update

Because of the need for additional researchers in the interdisciplinary field of behavioral health services research, the Florida Mental Health Institute at the University of South Florida developed and pilot tested a summer research institute for undergraduate students. Participants completed a 6-week program in which they developed a research project with a mentor and participated in a research seminar. The long-term objectives of the program were to attract promising students to the field and encourage them to pursue careers in behavioral health services research; short-term goals of the program were to strengthen participants’ research skills and knowledge, provide an intensive and enjoyable learning experience, and positively impact participants’ intentions to pursue graduate education in behavioral health. These goals were evaluated using a pre–post design with 6-month follow-up. Findings suggested that short-term goals were met. Suggestions for future improvements and implementation at other research settings are discussed.

Mental health service use and cost of care for older adults in assisted living facilities: Implications for public policy

Although several studies have examined the trend toward the decreasing differentiation of non-profit from for-profit general hospitals, few have focused on freestanding psychiatric hospitals. This study updates previous research that used psychiatric hospital data from calendar year 1986 with data from 1990. In addition, a preliminary examination of the influence of market competition on the behavior of non-profit psychiatric facilities was conducted. Results confirm a converging trend between for-profit and non-profit facilities that is related, in part, to competition.