Substitution in a Medicaid mental health carve-out: Services and costs
The objective is to empirically test the incentives associated with a Medicaid capitated mental health carve-out contract, whether outpatient services (less expensive, inside the contract) and residential treatment center care (costly care, outside of the contract) were substituted for inpatient psychiatric hospitalization used by children and adolescents. Data sources include Medicaid fee-for-service (FFS) claims for the non-capitated comparison sites and for residential treatment center use, and "shadow billing" encounter data for the experimental capitated managed care sites that provided public mental health services for children and adolescents with Medicaid insurance statewide in Colorado from September 1994 to June 1997. Two part least squares regression models are used to decompose services. Managed care sites are compared to sites that remained under FFS financing, before and in two post-periods after the carve-out. Principal findings show that children and adolescents who received mental health services from a capitated managed care provider were significantly less likely to receive inpatient care, and significantly more likely to receive residential treatment center care. In addition, insurance contract design contains financial incentives that affect the amount and mix of clinical care provided to clients by risk-bearing provider agencies. Findings provide evidence of cost substitution from inpatient care both inside the specialty system and outside the carve-out to other child-serving systems.
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ABSTRACT: PROLOGUE: Addressing the needs of children and adolescents with mental illness is a major challenge for health care policymakers in the new century. The scope of the problem is staggering. An estimated 20 percent of American children have emotional disorders, while mental health service-related expenditures topped $11.75 billion in 1998 alone. And, lest the severity of the impact of mental illness on the young be underestimated, the National Advisory Mental Health Council's workgroup on child and adolescent mental health has pointedly asserted that "no other illnesses damage so many children so seriously." Sadly, despite the obvious magnitude and urgency of the demand, development of a comprehensive, coordinated approach to meeting the needs of such children remains elusive. The Subcommittee on Children and Family of the President's New Freedom Commission on Mental Health has noted that while young people with emotional problems come in contact "with more than one specialized service system, including mental health, special education, child welfare, juvenile justice, substance abuse, and health…no agency or system is clearly responsible or ac- countable for them." However, amid such dour realities, reason for optimism exists in notable prog- ress that has been achieved over the past decade in the delivery and financing of mental health services for children. In the paper that follows, Sherry Glied and Allison Evans Cuellar report, among other things, on reductions in the out-of- pocket burden borne by families for children's mental health care. Moreover, more children have access to effective treatment, as the "evidence base" for making care decisions has steadily improved. Despite such advancements, though, Glied and Cuellar are quick to note the need for the allocation of greater resources toward formulation and identification of evidence-based community treatment models geared toward seriously ill children that are readily applicable to "existing service systems." Glied, a professor and department chair in the Mailman School of Public Health at Columbia University, served on the President's Council of Economic Advisers under George H.W. Bush and Bill Clinton and is a member of the John D. and Catherine T. MacArthur Foundation's network on mental health policy. Cuellar is an assistant professor at the Mailman School of Public Health.
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ABSTRACT: To evaluate the association between Medicaid mental health capitation and youth's involvement with the juvenile justice system.
A longitudinal, quasi-experimental pre/post design was used. Using administrative databases, juvenile justice contact, defined as any detention or commitment, was assessed for 13,365 Medicaid-eligible youths, aged 10-17 years, who received public mental health services over a 3-year period (1994-1997) in the state of Colorado.
There was no significant effect of financing when secular time was controlled for (interaction financing x time: hazard rate = 0.92, p =.62). The main effects model demonstrates a significant secular trend with juvenile justice contacts decreasing over time for both types of financing (hazard rate = 0.80, p =.002) and a significant effect of financing with eventually capitated sites having higher rates of juvenile justice contact compared with sites that remained fee-for-service (hazard rate = 1.24, p =. 009). Multivariate analyses controlled for demographics, mental health and substance use diagnoses, and other risk factors for juvenile justice contact.
After adjustment for secular trends, capitation was not associated with a reduction in juvenile justice contact. Nonetheless, these findings provide evidence that capitation did not increase the risk of juvenile justice contact.
Journal of the American Academy of Child & Adolescent Psychiatry 01/2003; 41(12):1462-9. DOI:10.1097/00004583-200212000-00018 · 7.26 Impact Factor
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ABSTRACT: Public sector mental health treatment has been transformed in recent years by the advent of managed care, but investigators of managed care policy have not yet focused on ethnic minority children, especially those involved with the child welfare system. Because of an overrepresentation of high-need minority children, foster care in particular is important to consider.
The present study examined children placed in foster care and documented differences between minority children and youth (black persons, Hispanic persons, and white persons) in use of mental health services. The primary concern of the study was to consider whether there were differences in access to services or service use among the groups in the transition to capitated managed care.
Medicaid claims and encounter data for two experimental managed care sites and one comparison fee-for-service site are used in a "difference-in-difference" analysis to estimate a changes in inpatient, outpatient, and residential treatment center (RTC) utilization, controlling for patient characteristics.
The study finds persistent declines in inpatient and outpatient use for all ethnic groups, persistent under-representation of Hispanic persons and black persons in treatment regardless of managed care, and greater use of RTCs by black persons and Hispanic persons that is attributable in part to managed care.
Black and Hispanic children received more rather than less mental health care under capitated managed care. The significance of this shift, largely increased in use of RTCs, however, cannot be determined at present, as the effectiveness of treatment delivered in RTCs is not known.
Medical Care 03/2003; 41(2):264-74. DOI:10.1097/01.MLR.0000044906.77195.8A · 3.23 Impact Factor
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