JBHSR Recent Issues
The Table of Contents and abstracts for recent issues of the JBHS&R are listed below.
Volume 28, 2001
Number 1 / January 2001
REGULAR ARTICLES
A Longitudinal Study of Adolescent Mental Health Service Use...1-11
Steven P. Cuffe, M.D., Jennifer Waller, Ph.D., Cheryl L. Addy, Ph.D., Robert McKeown, Ph.D., Kirby L. Jackson, A.B., Jamaluddin Moloo, M.D., M.P.H., and Carol Z.Garrison, Ph.D.
Abstract: This study examines longitudinal mental health service use patterns of a school-based sample of adolescents. Based on the Center for Epidemiological Studies Depression Scale scores, a stratified sample of middle schoolers were interviewed using the Schedule for Affective Disorders and Schizophrenia for School-aged Children: cycle one (N=579; mean age 12.83) and cycle two (N=490; mean age 18.65). Service use also was assessed by mailout questionnaire (cycle three, N=330; mean age 20.60). Service use decreased over time. Whites and males received significantly more treatment in the first cycle. In the second cycle, service use by race and gender was equal; in the mailout survey (third cycle), females received more treatment. In the first cycle 54% and in the second cycle 33% of those with a psychiatric diagnosis received treatment in the prior year. Under-treatment of youth with psychiatric diagnoses is a significant problem, with differences in service use by race and gender over time.
Managed Care and Outpatient Substance Abuse Treatment Intensity...12-29
Christy Harris Lemak, Ph.D. and Jeffrey A. Alexander, Ph.D.
Abstract: This study examines the extent to which managed care behavioral controls are associated with treatment intensity in outpatient substance abuse treatment facilities. Data are from the 1995 National Drug Abuse Treatment System Survey, a nationally representative survey that includes over 600 provider organizations with a response rate of 86%. Treatment intensity is measured in three ways: (1) the number of months clients spend in outpatient drug treatment; (2) the number of individual treatment sessions clients receive over the course of treatment; and (3) the number of group treatment sessions clients receive over the course of treatment. After accounting for selection bias and controlling for market, organization, and client characteristics, there is no significant relationship between the scope of managed care oversight and treatment intensity. However, the stringency of managed care oversight activities is negatively associated with the number of individual and group treatment sessions received over the course of treatment.
ADHD Treatment in a Behavioral Health Care Carve-out: Medications, Providers, and Service Utilization...30-41
Bradley Stein, M.D., M.P.H., and Maria Orlando, Ph.D.
Abstract: Children's mental health services are increasingly being managed by managed behavioral health organizations (MBHO) through carve-outs. Little information is available, however, about services and interventions being received by children whose mental health benefits are carved-out. Using claims data, this study explores the treatment of children with a common child psychiatric disorder, ADHD. Children being treated for ADHD see a variety of provider combinations. Children diagnosed with comorbid mood or anxiety disorders are more likely to see a psychiatrist than a primary care physician or therapist, and are more likely to be in treatment with both a psychiatrist and a therapist than with just one mental health professional. After controlling for severity indicators, costs were significantly lower for patients being treated by just a psychiatrist than for patients seeing both a psychiatrist and therapist. This finding raises the possibility that attempts to save money by "splitting treatment" may not be cost-effective.
The Long Term Treatment Outcomes of Depression and Anxiety Comorbid with Substance Abuse...42-57
Gregory Bovasso, Ph.D.
Abstract: The impact of the comorbidity of psychiatric disorder and substance abuse on treatment outcomes in the general population was estimated using data from a longitudinal survey of 1,920 individuals who were randomly sampled and followed over a nearly 15 year period. Individuals with anxiety or depression symptoms at baseline generally experienced increased distress at follow-up, but those with symptoms who received mental health treatment experienced decreased distress at follow up. Individuals with substance abuse/dependence symptoms who received treatment at baseline had a higher risk of follow up disability, but treated individuals with substance abuse who had comorbid anxiety and depression symptoms at baseline were at lower risk of disability at follow up. Individuals with anxiety and depression symptoms at baseline had a higher incidence of chronic illness during follow up, but those who received treatment or had substance abuse symptoms did not. An explanation of the results in terms of "confounding by indication" is unlikely given the pattern of results and the statistical control of the baseline severity of distress and dysfunction. The results may be explained in terms of "labeling effects" in individuals with substance abuse who receive treatment, or in terms of the greater insight of individuals with anxiety or depression who received treatment. The results may improve the understanding of the degree to which treatment of a primary disorder may be expected to prevent the incidence, or reduce the prevalence of a secondary, comorbid disorder.
Impact of VA Bed Closures on Use of State Psychiatric Services...58-66
Robert Rosenheck, M.D., Linda Frisman, Ph.D., and Susan Essock, Ph.D.
Abstract: This study examined whether a major reduction in inpatient beds at a VA Medical Center in 1996 increased VA patients' use of services provided by a State mental health agency. Veterans residing in two Connecticut cities who used VA psychiatric services during Fiscal Years (FY) 1993-FY 1998 (n=2,943) were identified from computerized VA files. Their records were merged with files from the Connecticut Department of Mental Health and Addiction Services (CT-DMHAS). Coinciding with the time of VA bed closures, the proportion of VA patients who used any CT-DMHAS services increased from 2.6%, 2.8% and 2.7% from 1993-95, to 3.6%, 3.5% and 3.6% from 1996-98 (p<.03). These changes reflect increased likelihood of using of CT-DMHAS outpatient services, but not inpatient services, presumably because CT-DMHAS also experienced substantial bed closures during that period. There were no statistically significant changes in the cost of CT-DMHAS services used by VA patients. The impact of bed closures may be reflected in increased cross-system service use which may be a useful indicator of unmet needs resulting from system changes.
Needs Based Planning Evaluation of a Level of Care Planning Model...67-80
Janet Durbin, MSc, Jeanette Cochrane, B.A., , Paula Goering, Ph.D., and Dianne Macfarlane, M.A.
Abstract: With closure of a number of provincial psychiatric hospitals planned, the Ministry of Health of Ontario has commissioned a series of planning projects to identify alternative placements for current hospital patients. The goal is to match need to care in the least restrictive setting. A systematic, clinically driven planning process was implemented which involved three steps: development of a continuum of levels of care representing increasingly intensive and more restrictive supports; development of criteria and decision rules for placement; and comprehensive needs assessment of current patients using the Colorado Client Assessment Record. Results showed that only 10% of current inpatients need to remain in hospital, and over 60% could live independently in the community with appropriate supports. Evidence supports concurrent validity of the planning model but further work is needed to assess whether recommended levels of care effectively meet consumer needs in the least restrictive setting.
BRIEF REPORTS
When Access to Care is Not Enough: Unmet Need for Populations in States With and Without Parity Legislation...81-88
Roland Sturm, Ph.D., and Cathy Donald Sherbourne, Ph.D.
Abstract: This paper provides estimates of unmet need and barriers to alcohol, drug, and mental health (ADM) services in 1997/1998, using data from a national household survey (N=9,585). In 1997/1998, 10.9 percent of the population perceived a need for ADM services, with 15 percent obtaining no treatment and 11 percent experiencing delays or obtaining less care than needed. The rate of unmet need due to no treatment is similar to earlier studies, but the group experiencing delays/less care is almost as large. This finding emphasizes the importance of defining access to care more broadly by including timeliness and intensity of care, not just access to some treatment. Economic barriers are highest for the uninsured, but are also high among the privately insured; supply-side constraints are commonly cited in public plans. Individuals with unmet need are significantly more likely to use complementary and alternative medicine (CAM) and the pattern differs by the reason for unmet need: Those with no conventional mental health care rely largely on self-administered treatment, while those with delayed/insufficient conventional care use CAM providers and self-administered treatment about equally.
The Mental Health Orientation of Juvenile Courts...89-95
Carolyn S. Breda, Ph.D.
Abstract: Effective systems of care for youth with emotional disorders require shared values among stakeholders toward a variety of mental health issues. Juvenile courts represent one stakeholder group whose values can affect the delivery of services to young offenders with or at risk of emotional disturbances. This research uses statewide data from Tennessee to assess the mental health orientation (MHO) of juvenile courts, their use of treatment options for offenders, and whether MHO influences the treatment referral decision. Results show that courts have a positive MHO, but this subjective orientation does not correspond to higher treatment referral rates. Moreover, service referrals are at a considerably lower rate than estimates of need for this population of youth would predict. While positive MHO suggests a basis for nurturing the shared courts' underutilization of treatment options for juvenile offenders.vision required for effective systems of care, other factors must be considered to account for jouvenile offenders.
Outcome Following Child Psychiatric Hospitalization...96-103
Susan Dickerson Mayes, Ph.D., Susan L. Calhoun, M.S., Valentins F. Krecko, M.D., Hillary P. Vesell, M.A., and Judy Hu, B.A.
Abstract: Admission, discharge, and follow-up (1 and 6 months) evaluations of 110 children admitted to a child psychiatric unit for a mean of 14 days showed that the children's psychological functioning improved significantly during hospitalization. Gains were not fully maintained at follow-up, but the children were still significantly less impaired 1 and 6 months after discharge than they were at admission. There was a nonsignificant difference between follow-up scores, indicating no loss of progress or decline in functioning from 1- to 6-months follow-up. The results are consistent with an ABA (A=no inpatient intervention, B=inpatient intervention, A=no inpatient intervention) treatment effect. They are not explained by removal from and return to an unsatisfactory home environment, because children from good environments showed the same ABA pattern. Psychological functioning after a mean 14-day admission was significantly better than after 1 to 6 months of post-discharge psychiatric services (e.g., psychotherapy, one-on-one behavior therapy, partial hospitalization, and/or residential care). This study offers a clinically feasible approach to evidence-based practice by documenting patient improvement during and after inpatient treatment using a simple and empirically supported assessment instrument.
Needs-based Planning for Persons with Serious Mental Illness Residing in Intermediate Care Facilities...104-110
Rachel L. Anderson, Ph.D., and John S. Lyons, Ph.D.
Abstract: This study examined the association of clinical status to mental health service use among persons with mental illness living in residential care. Two hundred residents with a chart diagnosis of schizophrenia were randomly selected from four intermediate care facilities. The Severity of Psychiatric Illness-Community Mental Health scale (SPI-CMH) was used to assess clinical status and symptom severity according to three dimensions: symptoms and functioning, risk behaviors, and complication to illness. Lower levels of severity of psychiatric illness were associated with participation in workshops, family contact, and admitting to mental health problems. Results suggest that residents of the intermediate care facilities have clinical needs consistent with habilitation and rehabilitation services. While residents infrequently engage in high risk behavior such as suicide and violence, they have considerable living skills and vocational needs. Future research should consider the relationship over time of mental health service utilization, severity of psychiatric illness, and psychosocial factors.
Number 2 / April 2001
SPECIAL SECTION:
Applications of Health Services Research in the Treatment and Prevention of Alcohol Abuse
Special Section Editors:
Dennis McCarty, PhD, Constance Weisner, DrPH, and Robert B. Huebner, PhD SPECIAL SECTION
Introduction
Dennis McCarty, PhD, Constance Weisner, DrPH, and Robert B. Huebner, PhD Prevention Research and Its
Actual Application to Health Services
Harold D. Holder, PhD
Abstract: The effectiveness of alcohol abuse programs, whether to treat dependent individuals or to prevent future problems, is of major importance to health services research. Demonstrating effectiveness has been appropriate to establish a sound scientific basis for treatment and prevention programs, and to increase public acceptance. Research has given good cause for optimism among people who provide and who fund treatment and prevention, i.e., optimism that programs can have the desired effects. In health services research, it is essential to analyze the costs of prevention efforts in terms of their demonstrated effectiveness in reducing health services demand. This priority requires documenting the true cost of design, implementation, and operation of a prevention program or policy. In the end, health services policy deliberations are optimally based on what effect is delivered for the cost of the service, not simply on a determination of which service is the most effective. However, in a time of scarce resources for all health programs, prevention should be studied with the same care and rigor as treatment in order to determine the best return for the investment.
The Provision of Services for Alcohol Problems: A Community Perspective for Understanding Access
Constance Weisner, DrPH
Abstract: Alcohol use is related to numerous health and social problems-problems that may affect where individuals with alcohol disorders are found across community agencies. The paper describes the prevalence of alcohol problems and dependence across a county and its institutions. High rates of problem drinking were found across health, mental health, criminal justice, welfare, drug, and alcohol programs. When the samples were weighted to reflect the overall representation of problem drinking across community agencies, the proportion of alcohol problems was highest for primary health clinics, the criminal justice system, and welfare agencies. Few of the county's problem drinkers were found in alcohol, drug, or mental health agencies. This was also the case when the county's most serious alcohol problem cases, individuals who were alcohol dependent, were examined. The findings suggest that it may be useful to develop screening procedures, to mainstream treatment interventions in non-alcohol specialty agencies, and to include non-specialty agencies in services research on access.
Public Sector Managed Care for Substance Abuse Treatment: Opportunities for Health Services Research
Dennis McCarty, PhD, Milton Argeriou, PhD, Gabrielle Denmead, and Joan Dilonardo, PhD
Abstract: Observations of reduced utilization of alcohol and drug abuse treatment following the introduction of managed behavioral health care suggests 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. It is important, therefore, to evaluate the impact of managed care on the delivery of alcohol and drug abuse treatments financed through Medicaid and other public resources. 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. Initiatives in each state are described and evaluation activities outlined. Opportunities and challenges associated with the assessment of public managed care plans are discussed.
REGULAR ARTICLES
Managed Care in the Public Sector: Lessons Learned from the Los Angeles PARTNERS Program
Greer Sullivan, MD, MSPH, Alexander S. Young, MD, MSHS, Stacey Fortney, BA, David Tillipman, PhD, Dennis Murata, MSW and Paul Koegel, PhD
Abstract: PARTNERS is a capitated, managed care treatment program implemented by the Los Angeles County Department of Mental Health to emphasize client empowerment and make better use of existing treatment funds. To explore the context in which public sector managed care reforms are occurring and to understand the obstacles to implementing such programs, qualitative data was collected from administrators, case managers, and clients. Administrators were found to need assistance in negotiating managed care contracts and in tracking costs effectively. Many case managers, although concerned about increased clinical demands, reported they enjoyed the flexibility and creativity allowed in their new roles. Also, clients were found to be highly satisfied with their increased independence, even though in most cases they were required to change their usual site of mental health care. Beyond the concerns of administrators, case managers, and clients, successful managed care interventions will need to consider the range of community stakeholders who may be affected by such interventions.
A Latent Variable Model of Evidence-based Quality Improvement for Substance Abuse Treatment
Richard D. Lennox, PhD and Alyssa J. Mansfield, MPH
Abstract: Attempts to improve the quality of substance abuse treatment are continually hampered by the field's inability to specifically define the elements of high quality of care, and more importantly, the lack of a research paradigm within which to study the necessary and sufficient elements of appropriate care. This study proposes that the quality of care (QOC) construct for substance abuse treatment might be best considered as a latent construct that does not necessarily exist as a single set of criteria, but instead is indicated by a set of empirically derived indicators manifested as a latent factor. A latent variable model of QOC for alcoholism treatment was tested by factor analyzing multiple indicators from claims records for patients being treated for alcohol dependence (n=335). Separate inpatient and outpatient models were found to adequately fit the data: outpatient model c2 = 1.66 (df =2, p=.437, GFI=.997; inpatient model c2 = 54.07 (df =2, p=.0001, GFI=.93). Results support defining latent QOC variables across levels-of-care for alcoholism treatment, and empirically defining latent QOC measures from administrative records.
A Five-Year Population Study of Persons Involved in the Mental Health And Local Correctional Systems: Implications for Service Planning
Judith F. Cox, MA, CCHP, Pamela C. Morschauser, MSW, CSW and Steven Banks, PhD
Abstract: This study investigates the relationship between recipients of mental health services and their incarceration within local jails. It represents the largest population-based study to date for which case-specific mental health and incarceration data were analyzed and the only study which reports on individuals booked into local jails over a five-year period. The study includes 117,736 New York State residents (aged 20 years and above) with a mental health diagnosis, who received a mental health service between 1991 through 1995, and 141,193 individuals who were incarcerated during the same timeframe. The incarceration rate was determined for the general population of the participating counties and for residents with a mental health diagnosis. It was found that there is a high rate of incarceration among persons in the general population, especially young males. The analyses showed that male and female recipients of mental health services are incarcerated in local jails at a higher rate than the general community but that most of them are not involved in long term prison incarcerations. The study further showed that the rate of incarceration for recipients of mental health services decreases with age but the relative risk of incarceration, when compared to the general population, actually increases with age. Additionally, across all age groups female recipients of mental health services were found to be at a much greater risk for incarceration within local jails compared to male recipients of mental health services.
Organizational Context and Provider Perception as Determinants of Mental Health Service Use
Arlene Rubin Stiffman, PhD, Catherine Striley, MSW, Violet E. Horvath, MSW, Eric Hadley-Ives, MSW, Michael Polgar, PhD, Diane Elze, PhD and Richard Pescarino, MA
Abstract: This paper refines and tests an individual client model of service use, and then contrasts it with a similar model of service provision based on gateway provider perspectives. In 1994 and 1996, 792 adolescents involved with public health, juvenile justice, child welfare, or education service sectors were interviewed. Two hundred twenty-two of their providers responded to a survey concerning service need, service use, and provider knowledge and behavior. Structural equation models demonstrate that provider variables account for more service use variation than client variables. The client model, accounting for 24% of the variance in service use, is typical of other tests of the Andersen model, while the provider model accounts for 55% of variation. Youth self-reported mental health was not positively associated with increased services, or with provider perception of youth mental health. The provider model demonstrates the critical role played by provider perceptions, which are influenced more by work environment (the organizational predisposing and enabling factors of burden and resource knowledge) than by client problems.
BRIEF REPORTS
The Health and Mental Health of Disabled Substance Abusers
Katherine E. Watkins MD, MSHS, Deborah Podus, PhD and Emilia Lombardi, PhD
Abstract: In 1996 Congress terminated Supplemental Security Income benefits to individuals disabled by substance abuse. Although most were expected to continue benefits under another disability category, 64% were not reclassified. This article examines data from a longitudinal study of individuals affected by the legislation in Los Angeles County to examine the health and mental health of the group at the time the legislation took effect and to analyze the relationship between health status at the time of the legislation and income source after the legislation. While poor physical health predicted both continued SSI benefits (OR 2.04, CI 1.02-4.07) and receipt of public income assistance (OR 3.25, CI 1.35-7.85) many individuals reporting significant mental and physical health problems were not reclassified and did not receive public income assistance, raising concern for their welfare. Local safety nets may become increasingly important for this population.
Rural-Urban Differences in Service Use for Memory-Related Problems in Older Adults
Neale R. Chumbler, PhD, Marisue Cody, PhD, Brenda M. Booth, PhD
and Cornelia K. Beck, PhD
Abstract: Policy analysts and behavioral health services researchers have been concerned that the reduced availability of providers and the travel difficulties encountered in accessing appropriate services in rural areas thwart older rural adults from getting the care they need for memory-related problems. The purpose of this study was to determine whether there were rural-urban differences in the probability of any service use of primary care physicians and mental health specialists, specifically for memory-related problems, in the full sample of older adults and in a subset of impaired respondents. This subset was identified by employing a process consistent with the DSM-IV criteria for dementia that requires both memory impairment and decline in functional ability. The authors recruited older adult subjects through a community-based telephone survey (i.e., random-digit dialing) of households with individuals ³ 60 years of age who resided in six southern states: Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee (n = 1,368). In the full sample, multivariate logistic regression results indicated that rural respondents were 0.66 times as likely (p = .06) to have used primary care physicians for memory-related problems compared with urban respondents. In the sub-group of respondents, multivariate logistic regression results indicated that rural individuals were 0.26 times as likely (p = .02) to have used primary care physicians for memory-related problems compared with urban respondents. In both groups, there were no rural-urban differences in the probability of mental health specialty use for memory-related problems. Further investigations are necessary to determine what causes rural residents to be somewhat less likely to use primary care physicians for memory-related problems before developing appropriate services to improve the care delivered to seniors with memory-related problems.
Number 3 / July 2001
SPECIAL SECTION:
Risk Adjustment in Mental Health
Special Section Editors: Michael Hendryx, PhD, Astrid Beigel, PhD, and Ann Doucette, PhD
Introduction
Risk-Adjustment Issues in Mental Health Service
Michael Hendryx, PhD, Astrid Beigel, PhD, and Ann Doucette, PhD
Abstract: State mental health authorities and other public and private entities are developing outcome measures and comparing results across providers, programs and systems. To make comparisons equitable, outcomes must be risk-adjusted. This paper provides an introduction to mental health risk-adjustment, and outlines issues involved in the selection of outcome and risk variables, data collection protocols, and analytic methods. The paper stresses the importance of the proper identification of risk-adjustment variables and models, and concludes with next steps necessary to develop a valid approach to risk-adjustment methodology.
Approaches to Risk Adjusting Outcome Measures Applied to Criminal Justice Involvement After Community Service
Steven M. Banks, PhD, John A. Pandiani, PhD, and Janet Bramley, PhD
Abstract: The ethic of fairness in program evaluation requires that measures of behavioral health agency performance be sensitive to differences in those agencies' caseload composition. The authors describe two traditional approaches to the statistical risk adjustment of outcome measures (stratification-weighting and pre-post measurement) that are designed to account for differences in caseload composition, and introduce a method that incorporates the strengths of both approaches. Procedures for deriving each of these measures are described in detail and demonstrated in the evaluation of a statewide system of community based behavioral health care programs. This evaluation examines the degree to which service recipients get into trouble with the law after treatment. Three measures are recommended for inclusion in outcome oriented "report cards" and the interpretation of each measure is discussed. Finally, the authors suggest formats for graphic and tabular presentation of the risk adjusted evaluation for sharing findings with diverse stakeholder groups.
Comparing Alternative Risk-Adjustment Models
Michael Hendryx, PhD, and Gregory B. Teague, PhD
Abstract: The use of mental health indicators to compare provider performance requires that comparisons be fair. Fair provider comparisons mean that scores are risk-adjusted for client characteristics that influence scores and that are beyond provider control. Data for the study are collected from 336 outpatients receiving publicly funded mental health services in Washington State. The study compares alternative specifications of multiple regression-based risk-adjustment models to argue that the particular form of the model will lead to different conclusions about comparative treatment agency performance. In order to evaluate performance fairly it is necessary not only to incorporate risk-adjustment, but also to identify the most correct form that the risk-adjustment model should take. Future research is needed to specify, test, and validate the mental health risk-adjustment models best suited to particular treatment populations and performance indicators.
Risk Adjustment of Florida Mental Health Outcomes Data: Concepts, Methods, and Results
Michael G. Dow, PhD, Timothy L. Boaz, PhD and David Thornton, MS
Abstract: The recent emphasis on developing outcome evaluation systems for mental health programs is discussed. Design and analysis methods for strengthening the validity of such uncontrolled comparisons are reviewed and critically evaluated. Methods for statistically adjusting pre-existing groups, now popularly referred to as risk adjustment or case-mix adjustment, are critically examined and guidelines are offered for determining when this procedure is appropriate. Analyses on two dependent variables--a global rating of functioning and a consumer satisfaction measure--available from an outcomes evaluation system currently underway in Florida are then used to demonstrate the proposed method of risk-adjustment. Results for 24 providers of mental health services showed that risk adjustment made a small difference in the overall rankings of the 24 providers, but some specific providers changed considerably in rank. The most potent risk adjustment variables included: education, involvement in the decision to enter treatment, age, global rating of functioning at admission, disabled classification, community stay prior to admission, psychotic diagnosis, substance use diagnosis, and employment prior to admission.
Implications of this research are discussed. Measuring Mental Health Outcomes with Pre-post Design
E. Warren Lambert, PhD, Ann Doucette, PhD, and Leonard Bickman, PhD
Abstract: The pre-post design has been the workhorse of outcome evaluations for many years. Using data from a study of 984 treated children (ages 5-17), this article argues that there are structural problems with the pre-post evaluation of outcome: a) excessively large intervals of uncertainty for individual outcomes; and b) paradoxical inconsistencies in the evaluation of groups. These problems can be solved by designs with three or more repeated measures analyzed with longitudinal multi-level analytic models.
Comparing Outcomes of Routine Care for Depression: The Dilemma of Case-Mix Adjustment
Teresa L. Kramer, PhD, Richard B. Evans, PhD, Reid Landes, MS, Michael Mancino, MD, Brenda M. Booth, PhD, and G. Richard Smith, MD
Abstract: The purpose of this study was to formulate and test two case-mix models for depression treatment that permit comparisons of patient outcomes across diverse clinical settings. Demographics, eight diagnostic-specific case-mix variables and clinical status at baseline and follow-up were assessed for 187 patients. Regressions were performed to test two models for four dependent variables, including depression severity and diagnosis. Individual treatment settings were then ranked based on a comparison of actual versus predicted outcomes using regression coefficients and predictor variables. A model inclusive of baseline physical health status and depression severity predicted depression severity, mental health and physical health functioning at follow-up. A simpler model performed well in predicting depression remission. This study identifies variables to be included in case-mix adjustment models and demonstrates statistical methods to control for differences across settings when comparing depression outcomes.
Risk Adjustment in the Hoosier Assurance Plan: Impact on Providers
Richard DeLiberty MSW, Ed Ward and Frederick L. Newman, PhD
Abstract: To support the administration of the non-Medicaid public behavioral health system, the Indiana Division of Mental Health designed a method for developing risk adjusted case rates. Rates were built upon multidimensional assessment instruments that identified a consumer's level of need. An algorithm was developed sorting consumers within each of three target populations, into groups by the relationship between their level of need and their similarity with regard to their service costs. The three target populations were: 1) adults with serious mental illness (SMI); 2) adults with a chronic addiction (CA); and, 3) children/ adolescents who are seriously emotionally disturbed (SED). Actuarially determined risk adjusted case rates were assigned to each group and applied to the case mix served by each provider in Indiana's public behavioral health system. This paper describes four studies through which a determination was made as to the applicability of the risk adjustment methodology. The results of the four studies supported using the adjusted case rates for adult consumers, but not for children/ adolescent consumers. Although the child/adolescent instrument did have adequate psychometric properties in a study involving 967 children and adolescents, the risk adjustment system based on it was not found to be reliable when tested in a three field. The adult system did sustain its reliability when tested under the same conditions.
REGULAR ARTICLES
National Estimates of Mental Health Utilization and Expenditures for Children in 1998
Jeanne S. Ringel, Ph.D and Roland Sturm, Ph.D
Abstract: There are efforts underway to reform the mental health system for children and adolescents, however no recent national data on expenditures and utilization are available to provide a benchmark. The most recent expenditure estimates, from 1986, predate the dramatic growth of managed care. This study uses a wide range of data sources to provide updated national estimates of child mental health costs. Treatment expenditures are estimated to be $11.68 billion or $172 per child. Adolescents have the highest expenditures per child at $293; $163 per child aged 6-11; and only $35 per preschool-aged child. Outpatient services account for 57%, inpatient for 33%, and psychotropic medications for 9% of the total. In contrast to earlier reports, outpatient care now accounts for the majority of expenditures. This finding replicates the differences between recent managed care data and earlier actuarial databases for privately insured adults and confirms the trend from inpatient toward outpatient care.
Insurance Status and Length of Stay for Involuntary Hospitalized Patients
William H. Fisher, PhD, Alisa K. Lincoln, MPH, PhD, Lorna J. Simon, MS, Kristen Roy-Bujnowski, BA, Andrew W. White, MA, Marylou Sudders, MSW, ACSW, and Paul J. Barreira, MD
Abstract: General and private psychiatric hospitals are becoming increasingly common as sites for involuntary hospitalization. Unlike the public facilities that these settings are supplanting, these hospitals must pay strict attention to issues associated with reimbursement, insurance status and managed care. This paper examines the effects of insurance status on length of stay for involuntarily hospitalized patients in general and private hospitals in Massachusetts. Using a two-stage sampling procedure, data on episodes of involuntary hospitalization were gathered from a statewide sample of general and private psychiatric hospitals in Massachusetts. The effect of insurance status was assessed using multiple regression in order to control for demographic and diagnostic characteristics as well as reasons for commitment. The primary effect of insurance was found between patients with Medicare, who had the longest stays, and individuals who were uninsured and had the shortest. Insurance type and whether or not it was managed were not significant factors when adjusted for patient characteristics. These data raise concerns about the sensitivity of the practice of involuntary hospitalization to economic factors in the new privatized psychiatric inpatient system that warrant closer scrutiny on the part of administrators and clinicians.
Toward a National Consumer Survey: Evaluation of the CABHS and MHSIP Instruments
Susan V. Eisen, PhD, James A. Shaul, MHA, Vickie Stringfellow, BA, H. Stephen Leff, PhD, and Paul D. Cleary, PhD
Abstract: This paper describes a study evaluating the Consumer Assessment of Behavioral Health Survey (CABHS) and the Mental Health Statistics Improvement Program (MHSIP) surveys. The purpose of the study was to provide data that could be used to develop recommendations for an improved instrument. Subjects were 3,443 adults in six behavioral health plans. The surveys did not differ significantly in response rate or consumer burden. Both surveys reliably assessed access to treatment and aspects of appropriateness and quality. The CABHS survey also reliably assessed features of the insurance plan, and the MHSIP survey reliably assessed treatment outcome. Analyses of comparable items suggested which survey items had greater validity. Results are discussed in terms of consistency with earlier research using these and other consumer surveys. Implications and recommendations for survey development, quality improvement and national policy initiatives to evaluate health plan performance are presented.
Number 4 / October 2001
REGULAR ARTICLES
Drinking Patterns, Health Care Utilization, and Costs Among HMO Primary Care Patients
Michael R. Polen, M.A., Carla A. Green, Ph.D., M.P.H., Donald K. Freeborn, Ph.D., John P. Mullooly, Ph.D., and Frances Lynch, Ph.D.
Abstract: To examine the relationship between alcohol consumption and health care costs and service use, 8034 primary care patients in a health maintenance organization (HMO) were surveyed to assess drinking patterns, sociodemographic characteristics, and other health behaviors. Costs were estimated from service use data for one year before and two years after study enrollment. No strong, consistent relationships were identified between multiple indicators of drinking patterns and either health care costs or service use. Compared to total costs among very light drinkers, former drinkers were higher, lifetime abstainers were similar, and persons in the higher drinking levels tended to have lower but not significantly different costs. Drinking patterns did not appear to be an important predictor of short-term health care costs or service use in this setting. Former drinkers, however, tended to have elevated costs, and deserve further study to examine the role of alcohol-related illnesses in the decision to quit drinking.
A Confirmatory Factor Analysis of the BASIS-32 in Racial and Ethnic Samples
Julian Chun-Chung Chow, Ph.D., Lonnie R. Snowden, Ph.D., and William McConnell, Ph.D.
Abstract: The present study performed confirmatory factor analysis across major racial and ethnic groups of the BASIS-32, a measure of functional status of persons receiving mental health treatment and suitable for routine assessment mental health care. The purpose was a preliminary investigation of cross-cultural equivalence in a county-level mental health program in a major metropolitan area. The results indicated a factor structure similar to that reported in the literature, and suggested acceptable levels of agreement in structure between racial and ethnic minority groups and whites. The study revealed little reason to believe that the BASIS-32 varied in underlying structure across racial and ethnic boundaries, although further research is indicated.
An Analysis of Stressors and Co-Morbid Mental Health Problems that Contribute to Youths' Paths to Substance-Specific Services
Sharon D. Johnson, Ph.D., Arlene Stiffman, Ph.D., Eric Hadley-Ives, M.S.W., and Diane Elze, Ph.D.
Abstract: Substance-specific services are tailored to address the inappropriate use of chemicals such as alcohol and marijuana. Unfortunately, the literature indicates that very few teens ever access such need-based services. This paper explores the paths to substance-specific service use in a sample of urban adolescents who are public service sector users. Results indicate that, even though a significant percentage of the youths frequently consume substances and display negative use-related behaviors, few actually received substance-specific services. The use of substance specific-services was via two paths: a direct path from substance misuse and an indirect path from general mental health service use. The contributors to the substance misuse path were youths' family substance dependence and environmental stressors. Contributors to the mental health services path included co-morbid depression and substance misuse. Youths' perceptions of barriers did not have the expected negative association with service use.
Utilization and Cost of Behavioral Health Services: Employee Characteristics and Workplace Health Promotion
James V. Trudeau, Ph.D., Diane K. Deitz, Ph.D., and Royer F. Cook, Ph.D.
Abstract:Objectives were to (1) model demographic and employment-related influences on behavioral healthcare utilization and cost; (2) model behavioral healthcare utilization and cost influences on general healthcare cost, job performance and earnings; and (3) assess workplace-based health promotion's impact on these factors. Behavioral healthcare utilization was more common in employees who were female, age 30+, with below-median earnings, or with above-median general (non-behavioral) healthcare costs. Among employees utilizing behavioral healthcare, related costs were higher for employees with below-median earnings. Employees utilizing behavioral healthcare had higher general healthcare costs and received lower performance ratings than other employees. Health promotion participants were compared to a non-participant random sample matched on gender, age, and pre-intervention behavioral healthcare utilization. Among employees without pre-intervention behavioral healthcare, participants and non-participants did not differ in post-intervention utilization. Among employees utilizing behavioral healthcare, adjusting for pre-intervention costs, participants had higher short-term post-intervention behavioral healthcare costs than non-participants.
Implications of these findings are discussed. Medicaid Patients in a Private Health Maintenance Organization: Patterns of Chemical Dependency Treatment
Lawrence J. Walter, M.A., Sujaya Parthasarathy, Ph.D., Steven Allen, Ph.D., and Lynn Ackerson, Ph.D.
Abstract: Although a large proportion of Medicaid beneficiaries now receive healthcare through commercial Health Maintenance Organizations (HMOs), the impact of private managed care on low-income individuals seeking treatment for substance abuse problems has rarely been studied. This study examined treatment patterns of 234 Medicaid recipients enrolled in Kaiser Permanente, a private HMO in northern California, who presented for care at the HMO's chemical dependency programs from 1995 to1997. After adjustment for demographic factors and duration of Health Plan membership, the Medicaid patients returned to start treatment after intake less often (OR=0.60) and dropped out of treatment sooner (median = 14 vs. 28 days) than non-Medicaid patients. Although many Medicaid patients did receive significant amounts of treatment, further research is needed to explain the treatment gap observed between Medicaid and non-Medicaid patients, which may reflect areas where the HMO needs to improve services for some of its most vulnerable members.
The Involvement of a Consumer Council in Organizational Decision Making in a Public Psychiatric Hospital
Donald M. Linhorst, Ph.D., M.S.W., Anne Eckert, B.A., R.N.C., Gary Hamilton, Ph.D., M.S.W., and Eric Young, M.S.W.
Abstract: This article describes a consumer group within a public psychiatric hospital that serves primarily a forensic population. Some barriers to participation included the severity of some clients' mental illness, an organizational culture that does not fully support participation, the lack of clients' awareness of problems or alternative actions, and inherent power imbalances between clients and staff. Despite these barriers, the consumer group has made improvements for facility clients. Some factors associated with this success included strong administrative support, the allocation of a highly qualified staff liaison to work with the group, and the integration of the group into the facility's formal decision-making structure. Lessons are offered for the development of similar groups within public psychiatric hospitals and community-based mental health agencies.
Does Managed Mental Health Care Reallocate Resources to Those with Greater Need for Services?
Margarita Alegría, Ph.D., Thomas McGuire, Ph.D., Mildred Vera, Ph.D., Glorisa Canino, Ph.D., Carmen Albizu, M.D., Heriberto Marín, Ph.D., and Leida Matías, Ph.D.
Abstract: A good deal of evidence points to the existence of two coexisting inefficiencies in mental health care resource allocation: Those with need receive too limited or no care while those with no apparent need do receive services. In addition to reducing costs, managed mental health care is expected to reallocate treatment resources to those with greater need for services. However, there are no empirical findings regarding this issue. In this paper we test whether managed mental health care had a differential impact by level of need. Data consist of three waves of a community sample with a control group. We find that managed care did not succeed in reallocating resources from the unlikely to the definite needers.
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The Accuracy of Medical Record Documentation in Schizophrenia
Julie Cradock, Ph.D., Alexander S. Young, M.D., M.S.H.S., and Greer Sullivan, M.D., M.S.P.H.
Abstract: Medical records are commonly used to measure quality of care. However, little is known about how accurately they reflect the clinical condition of patients. Even less is understood about what influences the accuracy of providers' documentation, and whether patient characteristics impact documentation habits. Discrepancies between symptoms and side effects evaluated by direct assessment and medical records were examined for 224 patients with schizophrenia at 2 public mental health clinics. Multivariate regression was used to study the relationship between patient, provider, and treatment characteristics and documentation accuracy. Overall, documentation of symptoms and side effects was frequently completely absent. Documentation varied substantially between clinics, and was generally less likely for patients who were severely ill, Black, or perceived as non-compliant. Inaccurate documentation may substantially influence evaluations of treatment quality. The accuracy and consistency of medical record documentation should be demonstrated before it is used to evaluate care at public mental health clinics.
Using a Computerized Patient Database to Evaluate Guideline Adherence and Measure Patterns of Care for Major Depression
Roland S. Chen, MD and Robert Rosenheck, MD
Abstract: This study examined the translation of recommendations from the Agency for Health Care Policy and Research (AHCPR) Guidelines for Major Depression into measures derived from a computerized database to assess guideline conformance and patterns of care for major depression. Patients (N=208) were identified who were hospitalized for major depression and had two or more outpatient mental health appointments within 6 months of discharge from an academically-affiliated Veterans Affairs Medical Center. Measures were based on AHCPR guideline recommendations or developed independently. Conformance could be measured for 3 guideline recommendations. Of patients on single-agent antidepressant therapy, 87% received dosages within the recommended range. Sixty-nine percent received the recommended number of follow-up visits. Specific condition-related treatment interventions were identified in 32% of patients with concurrent alcoholism. Dual diagnoses of depression and drug or alcohol abuse were not deterrents to prescribing benzodiazepines. Despite its limitations, computerized database analyses provided efficient measures of guideline adherence.
Understanding Urban Child Mental Health Service Use: Two Studies of Child, Family and Environmental Correlates
Mary M. McKay, Ph.D., L.C.S.W., James Pennington, M.S.W., Cynthia J. Lynn, M.S.W., and Kathleen McCadam, L.C.S.W.
Abstract: This paper presents the results of two studies that identify child, family, and environmental correlates of initial and ongoing mental health service use by urban, minority children and their families. In the first study, data were collected from a sample of 405 adult caregivers of children consecutively accepted for mental health services. Results revealed no predictive power of child demographic characteristics in relation to initial or ongoing service usage. Only parental ratings of child impulsive-hyperactive behavior were significantly related to ongoing involvement in services. In the second study, a new sample of 100 urban caregivers of children consecutively accepted for mental health services were interviewed. More extensive data regarding child and family characteristics, resources and needs were collected as well as environmental barriers to service usage. Parental discipline efficacy and parental attitudes about mental health services were found to significantly relate to initial attendance. In relation to ongoing service use, level of family stress, presence of another adult in the home, and parental discipline efficacy were significantly associated with ongoing involvement with mental health services.
Implications for child mental health service organizations and future research are highlighted. Raising Our Sites: Dissemination of Supported Education
Carol T. Mowbray, Ph.D., Chyrell D. Bellamy, M.S.W., Deborah Megivern, M.S.W., and Steve Szilvagyi, M.A.
Abstract: In order to promote replication of supported education, an exemplary rehabilitation model for adults with psychiatric disabilities, funds were accessed through a Community Action Grant from the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration (CMHS/SAMHSA). Three communities in Michigan participated in a multi-stage process, designed to maximize community ownership by encouraging local adaptations, involving all stakeholder groups, and providing technical assistance. The stages in the process were community organizing for supported education development, acquiring knowledge about supported education basics, information collection (needs assessment and barrier identification), and plan development. The process was successful in that all three sites have begun implementation, providing services to adults with psychiatric disabilities who wish to pursue post-secondary education. The community action approach utilized also has applicability for replicating other model programs in local communities.
