Risk-Adjusting Outcomes of Mental Health and Substance-Related Care: A Review of the Literature

Tufts University, Бостон, Georgia, United States
Harvard Review of Psychiatry (Impact Factor: 1.73). 03/2007; 15(2):52-69. DOI: 10.1080/10673220701307596
Source: PubMed


Risk adjustment is increasingly recognized as crucial to refining health care reimbursement and to comparing provider performance in terms of quality and outcomes of care. Risk adjustment for mental and substance use conditions has lagged behind other areas of medicine, but model development specific to these conditions has accelerated in recent years. After describing outcomes of mental health and substance-related care and associated risk factors, we review research studies on risk adjustment meeting the following criteria: (1) publication in a peer-reviewed journal between 1980 and 2002, (2) evaluation of one or more multivariate models used to risk-adjust comparisons of utilization, cost, or clinical outcomes of mental or substance use conditions across providers, and (3) quantitative assessment of the proportion of variance explained by patient characteristics in the model (e.g., R(2) or c-statistic). We identified 36 articles that included 72 models addressing utilization, 74 models of expenditures, and 15 models of clinical outcomes. Models based on diagnostic and sociodemographic information available from administrative data sets explained an average 6.7% of variance, whereas models using more detailed sources of data explained a more robust 22.8%. Results are appraised in the context of the mental health care system's needs for risk adjustment; we assess what has been accomplished, where gaps remain, and directions for future development.

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    • "These techniques are also applicable toward studying a variety of costs — health care costs, costs of mental health and substance use services, costs of disabilities, and costs of inpatient use. In their review, Hermann et al. (2007) examine studies reporting on a range of other outcomes, including functioning, symptom severity, satisfaction, and quality of life. Generally, risk adjustment methodologies are not as well developed for such client-derived outcomes as they are for utilization, cost, and clinical outcomes. "
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    ABSTRACT: Federal policymaking in the last decade has dramatically expanded performance measurement within child welfare systems, and states are currently being fiscally penalized for poor performance on defined outcomes. However, in contrast to performance measurement in health settings, current policy holds child welfare systems solely responsible for meeting outcomes, largely without taking into account the effects of factors at the level of the child, and his or her social ecology, that might undermine the performance of child welfare agencies. Appropriate measurement of performance is predicated upon the ability to disentangle individual, as opposed to organizational, determinants of outcomes, which is the goal of risk adjustment methodologies. This review briefly conceptualizes and examines risk adjustment approaches in health and child welfare, suggests approaches to expanding its use to appropriately measure the performance of child welfare agencies, and highlights research gaps that diminish the appropriate use of risk adjustment approaches -- and which consequently suggest the need for caution -- in policymaking around performance measurement of child welfare agencies.
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