Findings from the SAMHSA Managed Behavioral Health Care in the Public Sector Study. Judith A. Cook, Ph.D. Professor and Director Center for Mental Health Services Research & Policy Department of Psychiatry, University of Illinois at Chicago - PowerPoint PPT Presentation
Findings from the SAMHSA Managed Behavioral Health Care in the Public Sector Study Judith A. Cook, Ph.D. Professor and Director Center for Mental Health Services Research & Policy Department of Psychiatry, University of Illinois at Chicago Presented at Using Research to Move Forward: A Consensus Conference on Publicly Funded Managed Care for Children & Adolescents with Behavioral Health Disorders and Their Families September 29 & 30, 2003, Washington, DC
Transcript
Findings from the SAMHSA Managed
Behavioral Health Care in the Public Sector Study
Judith A. Cook, Ph.D.Professor and Director
Center for Mental Health Services Research & Policy Department of Psychiatry, University of Illinois at Chicago
Presented at Using Research to Move Forward: A Consensus Conference on Publicly Funded Managed Care for Children &
Adolescents with Behavioral Health Disorders and Their FamiliesSeptember 29 & 30, 2003, Washington, DC
Study Locations, Site and Coordinating Center PIs, &
Family Representative*Rural Counties in NW OregonPortland State UniversityRobert I. Paulson, Ph.D.
Tennessee and MississippiVanderbilt UniversityCraig Anne Heflinger, Ph.D.
Westchester County, New YorkColumbia UniversityChristina Hoven, Dr.P.H.
Rural Counties in Central PennsylvaniaUniversity of PittsburghKelly Kelleher, M.D.
Hamilton & Summit Counties, OhioPacific Institute for Research &
Evaluation,Al Stein-Seroussi, Ph.D.
Coordinating CenterUniversity of Illinois at ChicagoJudith A. Cook, Ph.D.
Family RepresentativeFederation for FamiliesValerie Burrell-Mohammed
*Funded by CMHS & CSAP of SAMHSA
Focus of the Study: Children with Severe Emotional Disorders
(SED)Inclusion Criteria DSM-IV Diagnosis Intensive Service Use (defined as use of any of the following:
inpatient, residential, day treatment, partial hospitalization, in-home support, rehabilitation, therapeutic foster care, special school, crisis services, intensive case management, or use of outpatient services 3 or more days/week)
Age: 4-17 years at time of sampling Medicaid-eligible In managed care or fee-for-service plan at baseline interview
Exclusion Criteria DSM-IV Diagnosis of solely MR, SA, or adjustment disorder Children with severe/profound MR/DD or those served primarily
through the MR/DD system(s)
Study Methodology• Parents and children were recruited through mailings to
households containing children with SED being served through MC and FFS plans; one site (OR) also used newspaper advertisements
• Response rates ranged from 10% to 98%• Consenting caregivers and children (age 11+ years) were
interviewed at study baseline (T1) and six month followup (T2) • Followup rate was 88% (N=1517); there were no attrition
differences re: child’s age, gender, functional impairment, health status, symptomatology, or caregiver strain; only significant difference was in race/ethnicity.
The Adult Respondent
The most knowledgeable caretaker of the child, including relatives (if
available) and professional caregivers (if not).
Managed Care Arrangements: Variations
at Different Sites• Who pays?
• For which services?
• For which children/adolescents?
• How is risk shifted?
Who Pays?OR PA TN
Medicaid
NY State Department of Health, Office of Managed Care County Medicaid Managed Care Provider Relations Protocol
OH
County DHS (61%) Medicaid, third party, and County funds (16%) County MHA (12%) County MR/DD (7%) County Juvenile Justice (4%) County SA (1%)
For Which Services?Service OR PA NY TN OH Psych. Inpt. No Residential No No No MH Outpt. Case Mgt. No In-Home Supp. No Psych. Meds. No No No No Subs. Abuse No
For Whom?OR All Medicaid Eligible Children/Adolescents
PA All Medicaid Eligible Children/Adolescents
(excluding children in custody except foster care)
NY Children with SED Children with SA disorders Children MR/DD
TN All Medicaid Eligible Children/Adolescents Uninsured Children Children up to 200% of federal poverty level
OH Highest utilizers
How is Risk Shifted?Traditional FFS Arrangement None
Managed Care Arrangement: Quasi-Governmental Org./Full Risk OR Private Org./Full Risk PA Private Org./Full Risk NY Private Org./Full Risk TN Private Provider Agency/Narrow Risk Corridor
OH
Research Questions Addressed Today
• Did psychiatric status, level of functional impairment, & likelihood of mental health service utilization differ significantly between children in managed care vs. fee-for-service arrangements?
• Did satisfaction with the child’s provider organization and behavioral health care plan differ significantly between caregivers of children in the two types of plans?
• Did caregivers’ ratings of provider service coordination differ for children in the two types of plans?
Description of the SampleMean Child Age (in years) 12 % Female Children 35 % Minority Children 46 % Children with Juvenile Justice Contact 28 % Caregivers with High School Education + 72 % Female Caregiver 95 Mean Caregiver Age (in years) 41 Mean Monthly Household Income $1936 Mean Number of People Living with Child 4.2 % Children Living in a Rural County 10 % Children Living in an Urban County 44 % In Managed Care 48 % From Oregon 16 % From PA 23 % From New York 19 % From Tennessee/Mississippi 20 % From Ohio 21
1st Research Question – Children’s Statuses &
Service Outcomes• Does the psychiatric status, level of
functional impairment, and likelihood of mental health service utilization differ significantly between children with SED served under managed care versus fee-for-service arrangements?
CIS)• Service Utilization (Services Utilization Instrument -
SUI)› Inpatient/Residential› Traditional Outpatient› Psychotropic Medication› Non-Traditional Services (i.e., day treatment, partial
hospitalization, in-home treatment, school-based services, case management, or group home care)
Levels of Functional Impairment and Psychiatric
SymptomatologyCIS baseline: 79% scored at or higher than the
clinical cutoff of 16.
CBCL Total baseline: over 50% scored above the clinical mean, indicating the presence of psychiatric symptoms characteristics of children being treated for mental health disorders
Proportion of Children Using Each Type of Service between T1
& T2Services FFS MC Total
Inpatient/Residential 13% 9% 11%*
Traditional Outpatient 64% 66% 65%
Psychotropic Medications 60% 52% 56%**
Non-Traditional Services 72% 61% 67%***
*p<.05; **p<.01; ***p<.001
Model Tested - Symptoms and Functioning
Block #1: T1 Score for Dependent Variable (CIS or CBCL)Block #2: Child Characteristics (age, gender, minority status,
Block #3: Caregiver Characteristics (education, gender, age, caregiver strain, physical health, mental health, satisfaction with behavioral health plan)
Block #4: Household/Neighborhood Characteristics (income, number of co-residents, urban neighborhood, rural neighborhood)
Block #5: Study Condition (managed care versus fee-for-service)Block #6: Site (TN/MS, OR, PA)
Results: Symptoms, Functioning, & Serice Use• There were no significant differences in the functional status of
children served in MC versus FFS arrangements• There were no significant differences in the psychiatric status of
children served in MC versus FFS arrangements, although a trend toward significance indicated somewhat poorer mental health status among children in the MC condition
• There were significant differences in the likelihood of some types of mental health service utilization but not others: Children in MC arrangements were significantly less likely to
receive inpatient/residential treatment Children in MC were significantly less likely to receive non-
traditional mental health services There was a trend toward significance in which children in MC
were somewhat less likely to receive psychopharmacologic treatment There was no significant difference in the likelihood of receiving
traditional outpatient mental health services
2nd Research Question - Satisfaction
• Does caregiver satisfaction with the child’s provider organization, and the child’s behavioral health care plan differ significantly between children served under managed care versus fee-for-service arrangements?
Caregiver Satisfaction with Behavioral Health Care
Provider Agency“Using any number on a scale from 0 to 10, where 0 is the worst possible care and 10 is the best possible care, what is your overall rating of the care [child’s name] has received from [the agency providing the most hours of service in the past six months].”
MC FFS Total Group
Average Score = 7 7 7
(difference non-significant)
Caregiver Satisfaction with Behavioral Health Care Plan
“Overall, what is your rating of [health care plan name] now? Use any number on a scale from 0 to 10, where 0 is as bad as a health insurance plan can be, 5 is okay or average, and 10 is as good as a health insurance plan can be.”
MC FFS Total Group*
Average Score = 7 8 7.5
* p <.001, difference remains significant controlling for site
Proportion Reporting Different Types of Provider Agency Satisfaction and
Relationship to 0-10 RatingUsually/Always
Got appointment promptly 80*Would recommend agency 83*Agency explained things well 86*Agency listed carefully 85*Agency aware of services 87*Involved caregiver in decisions 79*Caregiver treated with respect 91*
Significant relationship with 0-10 Provider Agency rating p <.05
Proportion Reporting Different Types of Health Care Plan Satisfaction/Dissatisfaction
& Relationship to 0-10 Satisfaction Rating
* Significant relationship with 0-10 Provider Agency Rating, p<.05
Easy to get MH/SA referral 68 +* Prescription MH/SA medicine available 91 +* Used service not covered by plan 54 -* Used provider not covered by plan 33 -* Refused to pay for drug Tx 8 -* Refused to pay for inpatient Tx 9 -* Problem finding provider that accepted plan 10 -* Refused to pay for outpatient treatment 4 -*
Block #6: Study Condition (managed care versus fee-for-service)Block #7: Site (TN/MS, OR, PA, OH)
Results: Provider & Plan Satisfaction
• There were no significant differences in level of satisfaction with the child’s provider agency (as rated by adult caregivers) between children served in managed care versus fee-for-service arrangements.
• Satisfaction with the child’s behavioral health care plan was significantly lower among caregivers whose children were enrolled in managed care versus fee-for-service plans. This was rue even controlling for characteristics of the child, caregiver, household/ neighborhood, child’s level of need, recent service utilization, and study site.
3RD Research Question: Service Coordination
Does the caregiver’s rating of degree of service coordination vary by whether the child was enrolled in a managed care plan versus a fee-for-service plan?
Service Coordination Scale (SCC)
• A set of 9 Likert-scaled responses to items asking caregivers about the degree to which the child’s service providers communicate & coordinate their service delivery efforts
• Administered to 266 caregivers of children & adolescents with SED, the scale had good psychometrics (high internal consistency, good construct validity with measures of satisfaction and family participation)
(Koren, Paulson, Kinney et al., 1997)
Degree of Service Coordination Among Providers as Assessed by Caregivers
Type of Coordination %
Providers worked together 65% Providers agreed on what child needed 72% Providers cooperated with each other 74%*
Providers were aware of all services child was receiving 73% Providers engaged in successful linkage/referral 46% Providers agreed about a single plan for child 66% New providers apprised of child’s situation 66% Providers not confused about how other providers are helping child
84%
Scale Cronbach’s alpha = .86 *Less likely among children in MC
Block #4: Child Need (child’s mental health symptoms)
Block #5: Site (TN/MS, OR, PA)Block #6: Study Condition (MC vs. FFS)
Results: Service Coordination• Most caregivers are fairly satisfied with the degree of
service coordination occurring on behalf of children and youth with SED.
• As perceived by their caregivers, children in MC behavioral health plans experience lower levels of service coordination than do children in FFS plans.
• This difference remained significant in multivariate models, even controlling for study site, caregiver strain, and caregiver physical health. Other significant predictors of service coordination include caregiver’s education, caregiver’s level of depression, and severity of child’s psychiatric symptoms.
Conclusions• While there were no differences between the functional
status & psychiatric symptom severity of children enrolled in MC vs. FFS plans, there was significantly lower utilization of some mental health services.
• There was lower satisfaction with the child’s behavioral health care plan among caregivers of children in MC arrangements compared to FFS.
• There was significantly lower service coordination among providers of children served in MC vs. FFS plans.
For further information
• Visit the website…www.psych.uic.edu/mhsrpstudy descriptiondownloadable protocolsresearch presentationslink to larger study
