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Special Report: Annotated Bibliography for
Managed Behavioral Health Care 1989-1999
Special
Populations
A. CHILDREN
334. Eisen, S., Griffin, M., Sederer, L., Dickey, B., & Mirin, S. M. (1995).
The impact of preadmission approval and continued stay review on
hospital stay and outcome among children and adolescents. The Journal
of Mental Health Administration 22(3), 270-277.
This article reports on results of a study that used a multiple regression model to predict the impact of utilization review on length of inpatient stay and clinical outcomes for children and
adolescents under 18 years of age. The independent variables used in the model included demographic and clinical characteristics, hospital ownership type, and pre-admission approval or continued stay review. Results of the study indicated that only two of the 10 predictor vari-ables
included in the model were statistically significant in predicting length of stay: previous psychiatric hospitalization and for-profit hospital status. The model was unsuccessful in accounting for a significant amount of the variance in hospital outcome. The authors conclude
with a discussion of limitations of the study, and the implications of the findings for health
care reform.
Keywords: children, outcomes, utilization management
335. Gresenz, C. R., Liu, X., & Sturm, R. (1998). Managed behavioral health
services for children under carve-out contracts. Psychiatric Services, 49(8),
1054-1058.
Amidst the recent growth in managed care organizations that specialize in administering
behavioral health care benefits apart from general health services, few studies have focused
on the effects of these new carve-out plans on children. In this study, researchers investigated
children’s cost and utilization patterns in carve-out plans and compared them with the pat-terns
of adults in these plans. From the results, adolescents in this plan were twice as likely
as adults and about seven times as likely as children ages 6 to 12 to use inpatient services.
Adolescents were also more likely than adults or other children to have higher inpatient
costs, while adults were the most likely to have higher outpatient costs. The authors conclude
that adolescents may benefit most from the elimination of caps on mental health care costs
covered by insurance.
Keywords: carve-outs, children, costs, utilization
336. Kaplan, D. W., Calonge, B. N., Guernsey, B. P., & Hanrahan, M. B.
(1998). Managed care and school-based health centers. Archives of
Pediatric and Adolescent Medicine 145, 25-33.
This article examines the use of physical and mental health services for adolescents who par-ticipate
in managed care organizations, comparing those who have access to school-based
health centers (SBHCs) to those who do not. The study specifically looked at the use of pri-mary
and specialty medical, mental health, substance abuse, preventative health, and urgent
care services. Results showed that adolescents with access to SBHCs were 10 times more
likely to make a mental health or substance abuse visit than non-SBHC students. Students
with access to SBHCs made one more medical visit per year, had decreased rates of use of
emergency or urgent care, were more likely to have one comprehensive health supervision
visit, and were more likely to be screened for high-risk behaviors than students without
access to SBHCs. SBHCs were shown to be very successful in improving access to treatment
for mental health and substance abuse problems and to comprehensive health supervision.
Keywords: children, school-based health, substance abuse, utilization
337. Jellinek, M., & Little, M. (1998). Supporting child psychiatric services
using current managed care approaches. Archives of Pediatric and
Adolescent Medicine, 152(4), 321-326.
This report details specific business approaches used by for-profit behavioral health care
companies that have carved out mental health services for children. First, the authors discuss
the evolution of managed mental health services and the negative implications of managing
the care of children by limiting access and shifting costs to the public sector and pediatricians.
These factors are not sufficiently counterbalanced by some of the positive changes, such as
lower costs from the decreased utilization of inpatient services within managed care, and
political pressure by legislative means. Ultimately, the commentary recommends that child
and adolescent psychiatric services should be reintegrated into the overall medical care of
children and families, and that market-driven managed care allocations are not the optimal
path to achieve high-quality mental health services for the Nation’s most vulnerable children.
Keywords: carve-outs, children
338. Lourie, I. S., Howe, S. W., & Roebuck, L. L. (1996). Systematic
approaches to mental health care in the private sector for children,
adolescents, and their families: Managed care organizations and service
providers. Washington, DC: Georgetown University Child Development
Center, National Technical Assistance Center for Child Mental Health.
In this study of private sector models for delivering mental health services to children, adoles-cents,
and their families, researchers examined five provider sites—two managed care organiza-tions
and three service provider agencies—all of which offer their own managed care products.
Among the findings are the lack of a true system of care in the private sector including mecha-nisms
for access to services, case management/coordination at the client level, coordination
across agencies, and mechanisms for financing services; the positive potential for managed care; and the growing private sector continuum of care. The book provides in-depth analysis
of managed care organizations, service providers, and public/private integration issues.
Appendices include site visit reports, values and principles for the System of Care outlined by
the Federal Child and Adolescent Service System Program, a list of advisers, a list of qualified
nominated organizations, and the private system of care questionnaire.
Keywords: children, evaluation, integration, models
339. Mason, M. J. (1998). School-based health clinics and the role of
mental health services: A review of the literature. Journal of Health and
Social Policy, 10(2), 1-13.
This article begins by establishing the heightening national concern about targeting mental
health and substance abuse problems in children, and points to goals cited in the Healthy
People 2000 initiative. It describes the origins and growth of the school-based health center
(SBHC) as a model of service delivery that effectively broadens access to health services in
general for children and adolescents. According to the author, SBHCs play an important role
in delivering counseling, assessment, and referral services for mental health and substance
abuse problems. A variety of issues affecting the proliferation of SBHCs are discussed, includ-ing
the need to build in systematic research protocols that would aid in accounting for the
cost-effectiveness of services delivered in these facilities. Some other issues addressed are
current and potential future sources of funding for SBHCs, the need for attention to public
relations concerns, and the impact of managed care on SBHCs. Managed care organizations
(MCOs) have traditionally been reluctant to contract with SBHCs because of the difficulty they
have in meeting practice guidelines of the MCOs. The article calls for research initiatives to
prove the importance and effectiveness of SBHCs in delivering mental health services to youth.
Keywords: children, overviews, school-based health, substance abuse
340. Nicholson, J., Young, S. D., Simon, L., Bateman, A., & Fisher, W. H.
(1996). Impact of Medicaid managed care on child and adolescent
emergency mental health screening in Massachusetts. Psychiatric Services,
47(12), 1344-1350.
This article reports on an initial evaluation of the impact of the Massachusetts Medicaid
managed mental health reform on service use and dispositions for children and youth
through an examination of the emergency mental health screening process. The study com-pared
client attributes and system characteristics (payer, referral source, and disposition) for
emergency mental health screenings for the year before and the first year after implementa-tion
of Medicaid managed care. The study found that after the implementation of managed
Medicaid mental health and substance abuse benefits, the volume of emergency mental
health screening for children and adolescence significantly increased, while the percentage of
inpatient admissions decreased. The authors further discuss these findings and the necessity
to address issues of quality of care and longer term savings.
Keywords: carve-outs, children, evaluation, Massachusetts, Medicaid, public sector
341. Nicholson, J., Young, S. D., Simon, L. J., Fisher, W. H., & Bateman, A.
(1998). Privatized Medicaid managed care in Massachusetts: Disposition
in child and adolescent mental health emergencies. The Journal of
Behavioral Health Services and Research, 25(3), 279-292.
Against the backdrop of Massachusetts’s transition to Medicaid managed care, this study
investigates two questions: the impact of privatized Medicaid managed care on the level of
care provided to children and adolescents with the greatest clinical need, and the relationship
between payer source and disposition. To answer these questions, the researchers examined
data from child and adolescent emergency mental health screening episodes before and after
privatized Medicaid managed care. They found that the transition to Medicaid managed care
decreases the likelihood of hospitalization by more than 60 percent for individuals covered by
Medicaid compared with those covered by HMOs. Additionally, privatized Medicaid managed
care does not seem to compromise quality of care, as measured by matching clinical need with
level of care. The authors describe the multiple forces shaping professional standards, decision
making, and quality of care as well as implications for behavioral health policymakers.
Keywords: carve-outs, children, evaluation, Massachusetts, Medicaid, utilization
342. Pumariega, A. J., Nace, D., England, M. J., Diamond, J., Fallong, T.,
Hanson, G., Lourie, I., Marx, L., Solnit, A., Grimes, C., Thurber, D., &
Graham, M. (1997). Community-based systems approach to children’s
managed mental health services. Journal of Child and Family Studies, 6(2),
149-164.
As managed care principles infiltrate into the children’s mental health service delivery system,
there is concern that they could deprive children of necessary intervention and prevention serv-ices.
In this paper, the authors review guidelines developed by the American Academy of Child
and Adolescent Psychiatry for the implementation of managed Medicaid contracts through
community-based systems of care principles. The authors describe the development and princi-ples
of the community-based systems approach as a means to ensure that the needs of seriously
emotionally disturbed children are met within the health system. The key principles of the sys-tem
of care approach include access to a comprehensive array of services, individualized treat-ment,
treatment in the least restrictive environment possible, full participation of families,
interagency coordination, early identification and intervention, care management, advocacy
efforts, effective transition into the adult system, and culturally sensitive services. The authors
also examine the community-based systems approach to managed care, including guidelines
on governance, benefit design, access to care, assessment, care plan development, treatment
services, care management, quality, provider supports, and information management.
Keywords: children, contracting, Medicaid, overviews
343. Scholle, S. H., Kelleher, K. J., Childs, G., Mendeloff, J., & Gardner,
W. P. (1997). Changes in Medicaid managed care enrollment among
children. Health Affairs, 16(2), 164-170.
This study looks at voluntary enrollment and disenrollment data for Medicaid managed care
in Allegheny County, PA, paying particular attention to patterns among children with mental
illness. Self-selection patterns for managed care versus fee-for-service are significant because
patients who voluntarily choose managed care are generally in better health and have lower
utilization of health care services. This phenomenon can distort data about managed care per-formance,
consumer satisfaction, cost savings, and other factors, and may benefit plans finan-cially
if capitation payments are not risk-adjusted. These authors are particularly concerned
with patients with mental illness, because managed care plans have traditionally provided a
low level of mental health services. Results of this study indicate that markers for more severe
mental illness were associated with lower levels of enrollment in managed care. In addition,
disabled children and those receiving cash assistance were less likely to enroll. Disenrollments
were higher for children with psychiatric conditions than for children with other conditions.
The authors discuss causes of these trends and make policy recommendations.
Keywords: children, Medicaid, Pennsylvania, public sector
344. Semlitz, L. (1996). Adolescent substance abuse treatment and
managed care. Child and Adolescent Psychiatric Clinics of North America,
5(1), 221-241.
This paper examines the impact of managed care on adolescent substance abuse treatment
planning and care delivery. The author describes the emergence of the managed care era from
the traditional fee-for-service system, including the types of managed care plans; the impact
on the doctor-patient relationship; responses of insurance companies/HMOs, hospitals, and
physicians to managed care; the idea of managed competition; and the trend toward capita-tion.
Other components of managed care reviewed include patient placement criteria, patient
treatment matching, outcome as a factor in treatment planning, treatment plan documenta-tion,
successful treatment plans, and utilization review. The author examines the impact of
managed care on substance abuse services and discusses ethical issues of managed care on
the doctor-patient relationship, such as the importance of patient confidentiality, standards
of review, and the prohibition of incentives to withhold care.
Keywords: children, substance abuse
345. Stroul, B. A., Pires, S. A., & Armstrong, M. I. (1998). Health care
reform tracking project: Tracking state managed care reforms as they
affect children and adolescents with behavioral health disorders and their
families. Tampa, FL: University of South Florida Research and Training
Center for Children’s Mental Health.
This is a report on calendar year 1997 of a 5-year project designed to track and analyze public
sector managed care reform targeting children and adolescents with emotional and substance
abuse problems and their families. The authors outline the specific goals of this report as describing the managed care reforms that affect behavioral health care for children and
adolescents, analyzing the effects of these changes, and identifying both problem areas and
effective strategies to help refine managed care systems for this vulnerable population. This
report surveys all of the States on a broad range of managed care topics, and then analyzes
the impact through examples from in-depth site visits to a select sample of States. The track-ing
project finds that there is a wide variation in the extent to which States assume an active
role in designing and overseeing managed care systems for this population.
Keywords: children, overviews, public sector, substance abuse
B. ELDERLY
346. Colenda, C. C., Banazak, D., & Mickus, M. (1998). Mental health
services in managed care: Quality questions remain. Geriatrics, 53(8),
49-63.
This article is intended to be useful to primary care health professionals who may be called
upon to counsel their patients about decisions on whether to enroll in a Medicare managed
care plan. The authors are particularly concerned that patients be well informed about the
nature of mental health services delivered by these plans. In this article the authors profile
Medicare risk contract plans, identify pros and cons, define and explain the difference between
"carve-outs" and "carve-ins," and explain what patients should expect from a plan’s staffing
model with regard to adequate numbers of mental health providers. Finally, the article discuss-es
potential advantages and disadvantages of managed care plans specific to the prevention
and treatment of Alzheimer’s disease.
Keywords: elderly, HMOs, overviews
347. Robinson, G. K., Crow, S. E., & Scallet, L. J. (1998). Managed care
policy: Meeting the mental health needs of the aged? Generations, 22(2),
58-62.
With many States moving to managed care in an effort to control public health care costs,
the question arises of how managed care will affect mental health care for the elderly. This
paper explores the approaches States are taking to manage public mental health services.
In particular, the researchers focus on the advantages and disadvantages of integrated and
carved-out mental health services as well as the different types of reimbursement. They
describe one example of a program enrolling people eligible for both Medicaid and Medicare
as a potential model for other programs for mental health care for the elderly. Finally, the
authors present some policy questions concerning the methods and feasibility of managed
mental health plans for the elderly.
Keywords: elderly, overviews, public sector
C. ETHNIC GROUPS
348. Dana, R. H. (1998). Problems with managed mental health care for
multicultural populations, Psychological Reports, 83, 283-294.
This article suggests that current psychological treatment is inadequate in its consideration and
treatment of multicultural populations. It explains that historically, interventions in the United
States were designed primarily for Americans of European descent, and thus were oriented
toward Caucasian patients. The author argues that managed care has reduced the availability
and quality of these interventions for all patients and further limited the evolution and diversi-fication
of treatment toward nonwhite patients. Culturally competent mental health services
are described and related to the quality of care. An agenda for the implementation of culturally
sensitive services is suggested.
Keywords: ethnic groups
349. Snowden, L. R. (1998). Managed care and ethnic minority populations.
Administration and Policy in Mental Health, 25(6), 581-592.
This article addresses the impact on minority populations of changes in mental health practice
patterns and utilization resulting from managed care. Differences in utilization of the mental
health system across racial/ethnic groups and problems with the cultural appropriateness or
accessibility of mental health services preceded the advent of managed care growth. Nonethe-less,
these problems take a new form within the context of managed care. While oversight,
coordination, and accountability may be beneficial aspects of managed care for minorities,
other aspects can be detrimental. The inflexibility of when and where services can be accessed
and the potentially intimidating and confusing nature of the bureaucracy are potential prob-lem
areas. Additionally, the average cost of care per patient differs across ethnic groups,
meaning that a reimbursement strategy based on capitation may create incentives to under-treat
these clients or avoid covering them altogether. Further areas of concern are addressed,
and some policy solutions are proposed.
Keywords: capitation, ethnic groups, overviews
D. WOMEN
350. Glied, S. (1997). The treatment of women with mental health
disorders under HMO and fee-for-service insurance. Women & Health,
26(2), 1-16.
This report analyzes data on office visits by women with mental health problems from 1990
to 1994 to examine characteristics of office visits by payment type. The study finds that the
expansion of managed care practices may harm the treatment of women with mental health
problems. Specifically, women enrolled in HMOs are more likely to see a primary care physi-cian
rather than a specialist, and of the women in specialty care, those in HMOs are more Special Report 136
likely to have medications substituted for psychotherapy than are those with fee-for-service
payments. The author suggests that a possible solution might be to allow self-referral for
women to lower cost specialty care.
Keywords: HMOs, women
351. Huskamp, H. A., Azzone, V., & Frank, R. G. (1998). Carve-outs,
women, and the treatment of depression. Women’s Health Issues,
8(5), 267-282.
This article examines the impact of "carving out" mental health services on the treatment
of depression in women. The first part of the article provides background information on
behavioral health care carve-outs, describing the market functions of the two general forms
of carve-outs, the health plan subcontract, and the payer carve-out. The authors provide an
overview of women and depression and suggest some possible effects of carve-outs on the
treatment of depression in women. The authors then report on their analyses of three separate
employer-based data sets, which allowed them to examine the impact of behavioral health
carve-outs on service utilization and spending for women with a diagnosis of depression.
The first data set was used to examine a cross section of health plans. The other data sets
were used to look at pre-/post-comparison of a health plan subcontract model and an
employer carve-out model.
Keywords: carve-outs, costs, depression, utilization, women
352. Newell, A. R., & Saltzman, G. M. (1997). The impact of managed
mental health care on women. Journal of the American Medical Women’s
Association, 52(2), 69-74.
Based upon differences in epidemiological patterns of mental illness in men and women,
aspects of psychodynamic theory, and evidence from outcome and cost studies, these authors
suggest that managed behavioral health care will have a differential impact on the receipt of
mental health care by women. Women are more likely to seek mental health services, to be
diagnosed with conditions that require care exclusively through the health care system, and to
have conditions such as eating disorders or trauma from abuse that require long-term treat-ment.
Various restrictions and cost-saving strategies involved in managed care strategies will
therefore disproportionately affect women. This article argues that certain managed care cost-saving
strategies do not make sense in light of evidence from cost-benefit studies of mental
health services. Instead, the authors argue for more focused and appropriate managed care
interventions, innovation in treatment methods, and legislation for minimum standards.
Keywords: overviews, women
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