The economics of behavioral health carve-outs.
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Behavior Therapy↗
Biomedical subjects
R G Frank
Publications and source records attributed to R G Frank.
Images in clinical urology. Venous cavernous hemangioma of the testis.
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Aged↗
Trajectories of adaptation in pediatric chronic illness: the importance of the individual.
This study used individual growth modeling to examine individual difference and group difference models of adaptation. The adaptation of 27 children with juvenile rheumatoid arthritis (JRA) and 40 children with insulin-dependent diabetes mellitus (IDDM) was tracked for 18 months from diagnosis. A control group of 62 healthy children was followed over the same time period. Clustering procedures indicated that child and family adaptation could be described by a number of distinct adaptation trajectories, independent of diagnostic group membership. In contrast, parental adaptation trajectory was associated with diagnostic group membership and control over disease activity for the JRA group and with diagnostic group membership for healthy controls. The observation of common patterns across trajectory sets, as well as the finding that trajectories were differentially related to a number of variables of interest, support the use of trajectories to represent adaptation to chronic disease.
Adaptation, Psychological↗
Factors influencing waiting time and successful receipt of cadaveric liver transplant in the United States. 1990 to 1992.
OBJECTIVES: Despite concern about access to liver transplantation, there has been no nationally based analysis of patients waiting for cadaveric liver transplant. Using data from the United Network for Organ Sharing Organ Procurement and Transplantation Network database waiting and recipient lists, we examined the influence of medical and non-medical factors on the length of time patients waited before transplant and whether they survived the wait. METHODS: The authors analyzed 7,422 entries to the waiting list from October 1, 1990 to December 31, 1992. Using Cox Proportional Hazard models, time to transplant was modelled by gender, nationality and ethnicity, age, blood type, medical status (critically ill versus non-critical), transplant number (first versus retransplant), United Network for Organ Sharing region of the country, and three measures of local demand and supply of organs. The risk of dying before being allocated an organ was compared with receiving an organ using multiple logistic regression models. RESULTS: In addition to differences by medical status, blood type, geographic region, and organ supply and demand, it was found that women, Hispanic-Americans, Asian-Americans, and children waited longer for transplant, whereas foreign nationals and repeat transplant patients waited fewer days. The risk of dying before transplant was greater for critically ill and repeat transplant patients, as well as for women, older patients, Asian-Americans, and African-Americans. Children were less likely to die, as were patients from certain blood groups and geographic regions. CONCLUSIONS: Results confirm known patterns of waiting list experience for liver transplant patients, but also identify factors previously unrecognized as influencing waiting time and outcome. Potential explanatory factors and areas for further inquiry are discussed.
Adolescent↗
Risk adjustment of mental health and substance abuse payments.
This study used 1992 and 1993 data from private employers to compare the performance of various risk adjustment methods in predicting the mental health and substance abuse expenditures of a nonelderly insured population. The methods considered included a basic demographic model, Ambulatory Care Groups, modified Ambulatory Diagnostic Groups and Hierarchical Coexisting Conditions (a modification of Diagnostic Cost Groups), as well as a model developed in this paper to tailor risk adjustment to the unique characteristics of psychiatric disorders (the "comorbidity" model). Our primary concern was the amount of unexplained systematic risk and its relationship to the likelihood of a health plan experiencing extraordinary profits or losses stemming from enrollee selection. We used a two-part model to estimate mental health and substance abuse spending. We examined the R2 and mean absolute prediction error associated with each risk adjustment system. We also examined the profits and losses that would be incurred by the health plans serving two of the employers in our database, based on the naturally occurring selection of enrollees into these plans. The modified Ambulatory Diagnostic Groups and comorbidity model performed somewhat better than the others, but none of the models achieved R2 values above .10. Furthermore, simulations based on actual plan choices suggested that none of the risk adjustment methods reallocated payments across plans sufficiently to compensate for systematic selection.
Actuarial Analysis↗
Differences in the use of psychiatric outpatient services between the United States and Ontario.
BACKGROUND: The relation between health insurance and the use of mental health services is unclear. We compared the use of outpatient services for psychiatric problems in the United States and Ontario, Canada, among young and middle-aged adults according to self-reports of disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) and to other indicators of need. METHODS: We analyzed two general-population surveys carried out separately in the United States and Ontario in 1990 that used identical assessments of need for services and questions about their use by persons 15 to 54 years of age. RESULTS: Respondents in the United States were significantly more likely than those in Ontario to report having had psychiatric disorders, poor mental health, or workdays lost or cut short because of psychiatric problems in the previous year. A significantly higher proportion of respondents in the United States (13.3 percent) than in Ontario (8.0 percent) had obtained outpatient treatment in the previous 12 months for psychiatric problems. However, an analysis of subgroups found that the higher probability of the use of services in the United States was confined to people with less severe mental illness. The average number of visits did not differ significantly between the two countries among patients who had similar numbers of psychiatric disorders over the same time periods. There was a stronger match in Ontario than in the United States between the use of services and the measures of perceived need we considered. CONCLUSIONS: Although the mental health care system in the United States provides treatment to a larger proportion of the population than that in Ontario, the match between some measures of need and treatment is not as strong in the United States. Any plans to expand coverage for psychiatric disorders in the United States must address this problem.
Adolescent↗
The market for residential and day schools for children with severe emotional disturbance.
This article describes the market for residential and day programs that provide education and treatment services on site for children with severe emotional disturbance (SED) in terms of the market's size, cost, and ownership mix. As policymakers encourage integration of services across sectors, this research fills a gap in the mental health services literature by providing a baseline of information on facilities from the education sector. Data are used from a national, stratified sample survey of separate day and residential schools for children with handicaps conducted by the Department of Education. There are 1,523 facilities providing educational and treatment services to 117,720 children with SED. Over half of the facilities are nonprofit, one-third are public, and less than one-tenth are for-profit. These programs represent a significant market of services for children with SED. Substantial differences in cost exist across ownership form that cannot be attributed to differences in size of facility or case mix of children enrolled.
Child↗
The 46th annual John Stanley Coulter Lecture. Lessons from the great battle: health care reform, 1992-1994.
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Health Care Reform↗
Rupture of a large calyceal diverticulum.
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Aged↗
The impact of psychiatric disorders on work loss days.
BACKGROUND: To examine relationships between recent DSM-III-R psychiatric disorders and work impairment in major occupational groups in the US labour force. METHOD: Data are from the US National Comorbidity Survey (NCS), a survey of respondents ages 15-54 in the US. Employed people are the focus of the report. RESULTS: There is substantial variation across occupations in the 30-day prevalences of NCS/ DSM-III-R psychiatric disorders, with an average prevalence of 18.2% (range: 11.0-29.6%) for any disorder. The average prevalences of psychiatric work loss days (6 days per month per 100 workers) and work cutback days (31 days per month per 100 workers), in comparison, do not differ significantly across occupations. Work impairment is more strongly concentrated among the 3.7% of the workforce with co-morbid psychiatric disorders (49 work loss days and 346 work cutback days per month per 100 workers) than the 14.5% with pure disorders (11 work loss days and 66 work cutback days per month per 100 workers) or the 81.8% with no disorder (2 work loss days and 11 work cutback days per month per 100 workers). The effects of psychiatric disorders on work loss are similar across all occupations, while effects on work cutback are greater among professional workers than those in other occupations. CONCLUSION: The results reported here suggest that work impairment is one of the adverse consequences of psychiatric disorders. The current policy debate concerning insurance coverage for mental disorders needs to take these consequences into consideration.
Absenteeism↗
Transactional patterns of child, mother, and father adjustment in insulin-dependent diabetes mellitus: a prospective study.
Utilized both interview and self-report methods to examine transactional patterns of child, mother, and father adjustment in a sample of children and adolescents with insulin-dependent diabetes mellitus (IDDM). Overall, levels of child and parental adjustment were relatively stable over the 1-year study period. Regression analyses revealed that increases in fathers', but not mothers', distress over time contributed significant incremental variance to poorer subsequent children's adjustment, after controlling for demographic (age, gender, and SES) and disease parameters (illness duration and metabolic control). Decline in fathers' adjustment was a significant predictor of better mothers' adjustment at follow-up; child adjustment was not significantly associated with mothers' adjustment. Variations in both children's and mothers' adjustment made significant, independent contributions to predicting subsequent fathers' adjustment. Findings illustrate the transactional nature of relationships that exist in families of children with IDDM and underscore the importance of family systems or biobehavioral family treatment approaches in the clinical management of children with chronic illnesses.
Adaptation, Psychological↗
Savings from a Medicaid carve-out for mental health and substance abuse services in Massachusetts.
OBJECTIVE: The study examined the financial performance of a managed behavioral health care organization responsible for mental health and substance abuse services under the Massachusetts Medicaid program. Financial performance is considered in light of incentives in the contract between the managed care firm and Medicaid. METHODS: Data on the financial performance of the managed care organization were obtained from documents related to a recent rebidding of the contract and other publicly available documents. Financial incentives associated with claims costs and administrative services are also reported. RESULTS: Spending by the managed care organization was about 25 percent lower than projected expenditures adjusted for inflation. Explicit financial incentives associated with cost reduction did not give the managed care organization strong inducements to attain these savings. The profit and loss features based on cost targets were quite limited. The organization had a much greater incentive and opportunity to make profits by conserving its administrative costs rather than by controlling Medicaid claims costs. CONCLUSIONS: In light of the contract's weak cost-saving incentives, it may be surprising that so much was saved. One explanation is that it was easy to achieve such savings in a state with high expenditures. However, in examining the particular amounts saved, it is clear that the organization came close to contract targets even when incentives to achieve them were weak. The authors label this behavior "managing to the contract" and discuss some reasons why a managed care organization might behave in this way and the implications this behavior has for contract design.
Contract Services↗
The use of outpatient mental health services in the United States and Ontario: the impact of mental morbidity and perceived need for care.
OBJECTIVES: This study compared the associations of individual mental health disorders, self-rated mental health, disability, and perceived need for care with the use of outpatient mental health services in the United States and the Canadian province of Ontario. METHODS: A cross-sectional study design was employed. Data came from the 1990 US National Comorbidity Survey and the 1990 Mental Health Supplement to the Ontario Health Survey. RESULTS: The odds of receiving any medical or psychiatric specialty services were as follows: for persons with any affective disorder, 3.1 in the United States vs 11.0 in Ontario; for persons with fair or poor self-rated mental health, 2.7 in the United States vs 5.0 in Ontario; for persons with mental health-related disability. 3.0 in the United States vs 1.5 in Ontario. When perceived need was controlled for, most of the between country differences in use disappeared. CONCLUSIONS: The higher use of mental health services in the United States than in Ontario is mostly explained by the combination of a higher prevalence of mental morbidity and a higher prevalence of perceived need for care among persons with low mental morbidity in the United States.
Cross-Sectional Studies↗
Alternative insurance arrangements and the treatment of depression: what are the facts?
Using insurance claims data from nine large self-insured employers offering 26 alternative health benefit plans, we examine empirically how the composition and utilization for the treatment of depression vary under alternative organizational forms of insurance (indemnity, preferred provider organization networks, and mental health carve-outs), and variations in patient cost-sharing (copayments for psychotherapy and for prescription drugs). Although total outpatient mental health and substance abuse expenditures per treated individual do not vary significantly across insurance forms, the depressed outpatient is more likely to receive anti-depressant drug medications is preferred provider organizations and carve-outs than when covered by indemnity insurance. Those individuals facing higher copayments for psychotherapy are more likely to receive anti-depressant drug medications. For those receiving treatment, increases in prescription drug copayments tend to increase the share of anti-depressant drug medication costs accounted for by the newest (and more costly) generation of drugs, the selective serotonin reuptake inhibitors.
Antidepressive Agents↗
Solutions for adverse selection in behavioral health care.
Health plans have incentives to discourage high-cost enrollees (such as persons with mental illness) from joining. Public policy to counter incentives created by adverse selection is difficult when managed care controls cost through methods that are largely beyond the grasp of direct regulation. In this article, the authors evaluate three approaches to dealing with selection incentives: risk adjustment, the carving out of benefits, and cost- or risk-sharing between the payer and the plan. Adverse selection is a serious problem in the context of managed care. Risk adjustment is not likely to help much, but carving out the benefit and cost-sharing are promising directions for policy.
Economic Competition↗
Mental health care use, morbidity, and socioeconomic status in the United States and Ontario.
This study focuses on mental health problems and compares the association of demographic and socioeconomic factors to the use of mental health specialty care and general medical care in the United States and the Canadian province, Ontario. It also examines how lack of insurance coverage in the United States and perceived need for care affects differences between the two countries. We employ a cross-sectional study design using the 1990 U.S. National Comorbidity Survey and the 1990 Mental Health Supplement to the Ontario Health Survey. Overall, 8.8% of Americans report one or more visits to the health sector for a mental health problem, compared to 6.9% of Canadians in Ontario. Americans with the highest incomes and no mental morbidity are much more likely to receive services than their Canadian counterparts. By contrast, Americans with the lowest incomes and high morbidity are much less likely to receive services for mental health problems than a similar group of Canadians. These results suggest that universal and comprehensive coverage, as exists in Ontario, does not necessarily lead to increased use of services with low value. However, the greater prevalence of perceived need for care among Americans with higher socioeconomic status and low mental morbidity suggests that the United States should be cautious in drawing lessons from other countries.
Adult↗
Some economics of mental health 'carve-outs'.
We discuss the rationale for benefit carve-out contracts in general and for mental health and substance abuse in particular. We focus on the control of adverse selection as a principal explanation and find that this is consistent with the wide-spread use of sole-source contracting with periodic rebidding. We also find that some degree of risk sharing is common; we interpret this as a method of balancing cost-containment incentives with incentives to maintain access and quality on unmeasured dimensions.
Capitation Fee↗
A family retreat as a comprehensive intervention for children with arthritis and their families.
OBJECTIVE: Family resources and coping skills are important to adaptation to pediatric chronic illness. Psychological and educational interventions have been found to enhance the coping skills of children with juvenile rheumatic disease (JRD) and their families. We examined the efficacy of a 3-day family retreat as a multidisciplinary, comprehensive treatment. METHODS: Children with JRD and their caregivers completed questionnaires assessing the children's behavioral and emotional functioning, pain, strain on caregivers' work and leisure activities, and caregivers' psychological distress before and 6 months after the family retreat. Principal caregivers were both parents for 16 children, mothers only for 10 children, and an aunt for 1 child. RESULTS: Improvements were found in children's emotional functioning, strain on caregivers' work, and strain on caregivers' leisure activities. Reductions in reported pain were not consistently revealed. CONCLUSIONS: Family retreats are an efficacious, multidisciplinary approach to helping families of children with JRD cope with the disease and its manifestations. Importantly, retreats offer a comprehensive intervention package that might not be available to families on an individual basis.
Adaptation, Psychological↗