Gerald Richardson, Linda Davies, Belinda South, Rebekah Proctor, Prof Alistair Burns, Hilary Stratton Powell, Prof Nicholas Tarrier, Brian Faragher
Background: The results of a randomized controlled trial have indicated that a training and educational programme for staff in nursing or residential homes may result in reductions in levels of depression and levels of cognitive impairment for residents presenting with an active management problem. The training and educational intervention consisted of members of a hospital outreach team who presented a series of 1 hour seminars on topics which staff had indicated would improve their knowledge and skills.
Aims of the study: The aim of this study was to present an exploratory analysis of the impact on costs associated with providing an old age psychiatry outreach team giving training and education for staff in nursing and residential homes.
Method: For the economic study, a societal perspective was employed. Measures of resource use and costs to the health service, social and community services and the nursing and residential homes were analysed for 120 residents from 12 nursing or residential homes, as part of a randomized controlled trial to assess a training package provided in residential and nursing homes. Cost estimates were based on estimates from generalized estimated equations. To allow for clustering effects within homes, the unit of randomization was the home as opposed to the individual. To ensure models were correctly specified, several tests including the Ramsey RESET test were employed.
Results: There were no significant differences in the total cost per person in the homes that received the intervention and the control homes. This study has shown that the additional cost of providing the specialist outreach team was likely to be covered by reductions in the use of other resources such as GP visits to nursing and residential homes. Therefore, though the study had limitations, it appeared that improved care could be provided at little or no extra cost.
<p><b>Background</b>: There are over 17 000 nursing homes in the United States. Within these, special care units (SCUs) provide a separate residential and/or activity locus for residents, and are expected to provide more staff time and more specialized staff assignments. This paper addresses a fundamental issue relating to the nature, quality and quantity of resident care inputs: what impacts of SCUs are associated with added service inputs, and thus with personnel costs, recognizing that personnel account for the majority of costs associated with nursing home care?</p><p><b>Aims of the study</b>: The aim of this aspect of the study was to determine the extent to which additions of staff would result in a diminution of deviant behaviors among residents of special care and of traditional care units.</p><p><b>Method</b>: The data were collected from a random sample of ten downstate nursing homes located in New York State. Using rigorous sampling procedures, random samples of 40 residents were drawn from each of the facilities, equally divided between special care unit and traditional care unit residents. Thus, the sampling design involved two levels of clustering: subjects were clustered within units and units were clustered within facilities. The observational behaviour measure was taken from the INCARE (institutional version of the Comprehensive Assessment and Referral Evaluation). The behavioral observation measure contains 23 items such as ‘disruptive of others’, ‘picks/pulls clothing’, ‘repetitive movements’, ‘repetitive questioning’ and ‘wandering’. Each item is rated as to frequency of occurrence; ratings are collected on three occasions, and averaged. Outcome and covariate data (e.g., behavior and cognition) were collected by trained research staff who visited each site for three to four weeks of intensive data collection, accomplished through direct resident interviews, staff interviews and questionnaires and chart data abstraction. The clinical staff <i>time</i> data were collected using the InfoAide system, whereby each care provider used a portable barcode scanner to record the type of care given, the recipient and the duration of care.</p><p>A random effects model using the SAS mixed procedure was applied to the data; adhering to this model, some effects were fixed and some random. The random effects were comprised of the subject (intercept or subject starting point at baseline) and the unit; used here was restricted maximum likelihood (REML) with the EM algorithm.</p><p><b>Results</b>: There was a significant reduction of behavior disorder associated with more provision of aide time in SCUs as contrasted with non-SCUs. The greater the service provided, the greater the slope, i.e., the greater the reduction. That is, while SCU residents showed improvements in behavior accompanying increases in aide time, no such change was observed among non-SCU residents.</p><p><b>Implications for Health Care Provision and Use</b>: The significant eff
{"title":"Service inputs and costs of care related to outcomes among cognitively impaired nursing home residents","authors":"Douglas Holmes, Jeanne Teresi, Jian Kong","doi":"10.1002/mhp.87","DOIUrl":"https://doi.org/10.1002/mhp.87","url":null,"abstract":"<p><b>Background</b>: There are over 17 000 nursing homes in the United States. Within these, special care units (SCUs) provide a separate residential and/or activity locus for residents, and are expected to provide more staff time and more specialized staff assignments. This paper addresses a fundamental issue relating to the nature, quality and quantity of resident care inputs: what impacts of SCUs are associated with added service inputs, and thus with personnel costs, recognizing that personnel account for the majority of costs associated with nursing home care?</p><p><b>Aims of the study</b>: The aim of this aspect of the study was to determine the extent to which additions of staff would result in a diminution of deviant behaviors among residents of special care and of traditional care units.</p><p><b>Method</b>: The data were collected from a random sample of ten downstate nursing homes located in New York State. Using rigorous sampling procedures, random samples of 40 residents were drawn from each of the facilities, equally divided between special care unit and traditional care unit residents. Thus, the sampling design involved two levels of clustering: subjects were clustered within units and units were clustered within facilities. The observational behaviour measure was taken from the INCARE (institutional version of the Comprehensive Assessment and Referral Evaluation). The behavioral observation measure contains 23 items such as ‘disruptive of others’, ‘picks/pulls clothing’, ‘repetitive movements’, ‘repetitive questioning’ and ‘wandering’. Each item is rated as to frequency of occurrence; ratings are collected on three occasions, and averaged. Outcome and covariate data (e.g., behavior and cognition) were collected by trained research staff who visited each site for three to four weeks of intensive data collection, accomplished through direct resident interviews, staff interviews and questionnaires and chart data abstraction. The clinical staff <i>time</i> data were collected using the InfoAide system, whereby each care provider used a portable barcode scanner to record the type of care given, the recipient and the duration of care.</p><p>A random effects model using the SAS mixed procedure was applied to the data; adhering to this model, some effects were fixed and some random. The random effects were comprised of the subject (intercept or subject starting point at baseline) and the unit; used here was restricted maximum likelihood (REML) with the EM algorithm.</p><p><b>Results</b>: There was a significant reduction of behavior disorder associated with more provision of aide time in SCUs as contrasted with non-SCUs. The greater the service provided, the greater the slope, i.e., the greater the reduction. That is, while SCU residents showed improvements in behavior accompanying increases in aide time, no such change was observed among non-SCU residents.</p><p><b>Implications for Health Care Provision and Use</b>: The significant eff","PeriodicalId":46381,"journal":{"name":"Journal of Mental Health Policy and Economics","volume":"3 3","pages":"121-127"},"PeriodicalIF":1.6,"publicationDate":"2001-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/mhp.87","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72169224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p><b>Background</b>: Publicly funded mental health systems are increasingly implementing managed care systems, such as capitation, to control costs. Capitated contracts may increase the risk for disenrollment or adverse outcomes among high cost clients with severe mental illness. Risk-adjusted payments to providers are likely to reduce providers' incentives to avoid or under-treat these people. However, most research has focused on Medicare and private populations, and risk adjustment for individuals who are publicly funded and severely mentally ill has received far less attention.</p><p><b>Aims of the Study</b>: Risk adjustment models for this population can be used to improve contracting for mental health care. Our objective is to develop risk adjustment models for individuals with severe mental illness and assess their performance in predicting future costs. We apply the risk adjustment model to predict costs for the first year of a pilot capitation program for the severely mentally ill that was not risk adjusted. We assess whether risk adjustment could have reduced disenrollment from this program.</p><p><b>Methods</b>: This analysis uses longitudinal administrative data from the County of Los Angeles Department of Mental Health for the fiscal years 1991 to 1994. The sample consists of 1956 clients who have high costs and are severely mentally ill. We estimate several modified two part models of 1993 cost that use 1992 client-based variables such as demographics, living conditions, diagnoses and mental health costs (for 1992 and 1991) to explain the variation in mental health and substance abuse costs.</p><p><b>Results</b>: We find that the model that incorporates demographic characteristics, diagnostic information and cost data from two previous years explains about 16 percent of the in-sample variation and 10 percent of the out-of-sample variation in costs. A model that excludes prior cost covariates explains only 5 percent of the variation in costs. Despite the relatively low predictive power, we find some evidence that the disenrollment from the pilot capitation initiative input have been reduced if risk adjustment had been used to set capitation rates.</p><p><b>Discussion</b>: The evidence suggests that even though risk adjustment techniques have room to improve, they are still likely to be useful for reducing risk selection in capitation programs. Blended payment schemes that combine risk adjustment with risk corridors or partial fee-for-service payments should be explored.</p><p><b>Implications for Health Care Provision, Use, and Policy</b>: Our results suggest that risk adjustment methods, as developed to data, do not have the requisite predictive power to be used as the sole approach to adjusting capitation rates. Risk adjustment is informative and useful; however, payments to providers should not be fully capitated, and may need to involve some degree of risk sharing between providers and public mental health agencies. A blended con
{"title":"Risk adjustment for high utilizers of public mental health care","authors":"Kanika Kapur., Alexander S Young, Dennis Murata","doi":"10.1002/mhp.85","DOIUrl":"https://doi.org/10.1002/mhp.85","url":null,"abstract":"<p><b>Background</b>: Publicly funded mental health systems are increasingly implementing managed care systems, such as capitation, to control costs. Capitated contracts may increase the risk for disenrollment or adverse outcomes among high cost clients with severe mental illness. Risk-adjusted payments to providers are likely to reduce providers' incentives to avoid or under-treat these people. However, most research has focused on Medicare and private populations, and risk adjustment for individuals who are publicly funded and severely mentally ill has received far less attention.</p><p><b>Aims of the Study</b>: Risk adjustment models for this population can be used to improve contracting for mental health care. Our objective is to develop risk adjustment models for individuals with severe mental illness and assess their performance in predicting future costs. We apply the risk adjustment model to predict costs for the first year of a pilot capitation program for the severely mentally ill that was not risk adjusted. We assess whether risk adjustment could have reduced disenrollment from this program.</p><p><b>Methods</b>: This analysis uses longitudinal administrative data from the County of Los Angeles Department of Mental Health for the fiscal years 1991 to 1994. The sample consists of 1956 clients who have high costs and are severely mentally ill. We estimate several modified two part models of 1993 cost that use 1992 client-based variables such as demographics, living conditions, diagnoses and mental health costs (for 1992 and 1991) to explain the variation in mental health and substance abuse costs.</p><p><b>Results</b>: We find that the model that incorporates demographic characteristics, diagnostic information and cost data from two previous years explains about 16 percent of the in-sample variation and 10 percent of the out-of-sample variation in costs. A model that excludes prior cost covariates explains only 5 percent of the variation in costs. Despite the relatively low predictive power, we find some evidence that the disenrollment from the pilot capitation initiative input have been reduced if risk adjustment had been used to set capitation rates.</p><p><b>Discussion</b>: The evidence suggests that even though risk adjustment techniques have room to improve, they are still likely to be useful for reducing risk selection in capitation programs. Blended payment schemes that combine risk adjustment with risk corridors or partial fee-for-service payments should be explored.</p><p><b>Implications for Health Care Provision, Use, and Policy</b>: Our results suggest that risk adjustment methods, as developed to data, do not have the requisite predictive power to be used as the sole approach to adjusting capitation rates. Risk adjustment is informative and useful; however, payments to providers should not be fully capitated, and may need to involve some degree of risk sharing between providers and public mental health agencies. A blended con","PeriodicalId":46381,"journal":{"name":"Journal of Mental Health Policy and Economics","volume":"3 3","pages":"129-137"},"PeriodicalIF":1.6,"publicationDate":"2001-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/mhp.85","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72169215","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Addiction:entries and exits. Edited by Jon Elster. New York: Sage, 1999","authors":"Rosalie Liccardo Pacula","doi":"10.1002/mhp.92","DOIUrl":"https://doi.org/10.1002/mhp.92","url":null,"abstract":"","PeriodicalId":46381,"journal":{"name":"Journal of Mental Health Policy and Economics","volume":"3 3","pages":"165-166"},"PeriodicalIF":1.6,"publicationDate":"2001-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/mhp.92","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72169220","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"The Adam Smith Award","authors":"","doi":"10.1002/mhp.99","DOIUrl":"https://doi.org/10.1002/mhp.99","url":null,"abstract":"","PeriodicalId":46381,"journal":{"name":"Journal of Mental Health Policy and Economics","volume":"3 3","pages":"167"},"PeriodicalIF":1.6,"publicationDate":"2001-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/mhp.99","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72169219","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p><b>Background:</b> The homeless population is among the poorest of the poor in the United States. Employment and government programs are potential sources of income, but many homeless people face potential barriers to work: many have serious mental and physical disabilities, and many more have alcohol and drug disorders. As a result, most homeless who work do so either for a few hours per day or only some days, which provides little income. General Assistance, a public program of last resort, also provides a low level of income support. More income might be gained through higher levels of work or participation in income support programs for people with disabilities.</p><p><b>Aims of the Study:</b> To investigate the characteristics of homeless people that impede them in the labor market and in government program participation, paying particular attention to their mental and physical health, as well as their alcohol and drug problems.</p><p><b>Data:</b> Data are from a survey of the homeless population in Alameda County, California, conducted from 1991 to 1993. Our sample is 471 homeless adults randomly selected from area shelters and meal providers, who were reinterviewed approximately 6 months later, regardless of domiciliary status. Mental health and substance use problems were assessed using the Diagnostic Interview Schedule, a structured, psychiatric interview that uses criteria based on the American Psychiatric Association's <i>Diagnostic and Statistical Manual of Mental Disorders</i> 3rd edn (revised). Employment between the first and second interview is categorized as none, low level (less than 6 hours a day or fewer than half the days between interviews) or higher level (at least 6 hours a day for at least half the days).</p><p><b>Analytical Procedures:</b> The models of employment status and program participation are recursive in that homelessness at the first wave of the survey is treated as given. Thus we explore whether, given their initial homelessness, persons can gain or maintain access to income between the two interviews, conditional on the sample member's homelessness, health and disability at the first interview. Using maximum-likelihood methods, we estimate a generalized ordered logit model of whether the person works not at all, at a low level or at a higher level. Participation in disability programs and GA are estimated as probit models over the subsamples of potentially eligible participants.</p><p><b>Results:</b> While a surprisingly large number of homeless people work, few homeless persons are able to generate significant earnings from employment alone. Physical health problems that limit work or daily activities, in particular, are barriers to employment. Drug and alcohol abuse and dependence are positively associated with lower work level but are negatively related to higher work level. Program participation is quite low relative to eligibility. Those with physical health problems are substantially more likely than
{"title":"Income and employment among homeless people: the role of mental health, health and substance abuse","authors":"Samuel H. Zuvekas, Steven C. Hill","doi":"10.1002/mhp.94","DOIUrl":"https://doi.org/10.1002/mhp.94","url":null,"abstract":"<p><b>Background:</b> The homeless population is among the poorest of the poor in the United States. Employment and government programs are potential sources of income, but many homeless people face potential barriers to work: many have serious mental and physical disabilities, and many more have alcohol and drug disorders. As a result, most homeless who work do so either for a few hours per day or only some days, which provides little income. General Assistance, a public program of last resort, also provides a low level of income support. More income might be gained through higher levels of work or participation in income support programs for people with disabilities.</p><p><b>Aims of the Study:</b> To investigate the characteristics of homeless people that impede them in the labor market and in government program participation, paying particular attention to their mental and physical health, as well as their alcohol and drug problems.</p><p><b>Data:</b> Data are from a survey of the homeless population in Alameda County, California, conducted from 1991 to 1993. Our sample is 471 homeless adults randomly selected from area shelters and meal providers, who were reinterviewed approximately 6 months later, regardless of domiciliary status. Mental health and substance use problems were assessed using the Diagnostic Interview Schedule, a structured, psychiatric interview that uses criteria based on the American Psychiatric Association's <i>Diagnostic and Statistical Manual of Mental Disorders</i> 3rd edn (revised). Employment between the first and second interview is categorized as none, low level (less than 6 hours a day or fewer than half the days between interviews) or higher level (at least 6 hours a day for at least half the days).</p><p><b>Analytical Procedures:</b> The models of employment status and program participation are recursive in that homelessness at the first wave of the survey is treated as given. Thus we explore whether, given their initial homelessness, persons can gain or maintain access to income between the two interviews, conditional on the sample member's homelessness, health and disability at the first interview. Using maximum-likelihood methods, we estimate a generalized ordered logit model of whether the person works not at all, at a low level or at a higher level. Participation in disability programs and GA are estimated as probit models over the subsamples of potentially eligible participants.</p><p><b>Results:</b> While a surprisingly large number of homeless people work, few homeless persons are able to generate significant earnings from employment alone. Physical health problems that limit work or daily activities, in particular, are barriers to employment. Drug and alcohol abuse and dependence are positively associated with lower work level but are negatively related to higher work level. Program participation is quite low relative to eligibility. Those with physical health problems are substantially more likely than","PeriodicalId":46381,"journal":{"name":"Journal of Mental Health Policy and Economics","volume":"3 3","pages":"153-163"},"PeriodicalIF":1.6,"publicationDate":"2001-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/mhp.94","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72169223","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p><b>Background:</b> Few studies have systematically compared the relationship between lost work productivity (work impairment) and mental disorders using population surveys.</p><p><b>Aims:</b> (1) To identify the importance of individual mental disorders and disorder co-occurrences (comorbidity) as predictors of two measures of work impairment over the past month—work loss (number of days unable to perform usual activities) and work cutback (number of days where usual activities were restricted); (2) to examine whether different types of disorder have a greater impact on work impairment in some occupations than others; (3) to determine whether work impairment in those with a disorder is related to treatment seeking.</p><p><b>Method:</b> Data were based on full-time workers identified by the Australian National Survey of Mental Health and Well-Being, a household survey of mental disorders modeled on the US National Comorbidity Survey. Diagnoses were of one-month DSM-IV affective, anxiety and substance-related disorders. Screening instruments generated likely cases of ICD-10 personality disorders. The association of disorder types and their co-occurrences with work impairment was examined using multivariate linear regression. Odds ratios determined the significance of mental disorder prevalence across occupations, and planned contrasts were used to test for differences in work impairment across occupations within disorder types. The relationship between work impairment and treatment seeking was determined for each broad diagnostic group with <i>t</i>-tests.</p><p><b>Results:</b> Depression, generalized anxiety disorder and personality disorders were predictive of work impairment after controlling for impairment due to physical disorders. Among pure and comorbid disorders, affective and comorbid anxiety–affective disorders respectively were associated with the greatest amount of work impairment. For all disorders, stronger associations were obtained for work cutback than for work loss. No relationship was found between type of occupation and the impact of different types of disorder on work impairment. Only 15% of people with any mental disorder had sought help in the past month. For any mental disorder, significantly greater work loss and work cutback was associated with treatment seeking, but comparisons within specific disorder types were not significant.</p><p><b>Discussion:</b> A substantial amount of lost productivity due to mental disorders comes from within the full-time working population. The greater impact of mental disorders on work cutback compared to work loss suggests that work cutback provides a more sensitive measure of work impairment in those with mental disorders. Work impairment was based on self-report only. While there is evidence for the reliability of self-assessed work loss days, no reliability or validity studies have been conducted for work cutback days. The low rates of treatment seeking are a major health issue for th
{"title":"Lost productivity among full-time workers with mental disorders","authors":"Debbie Lim, Kristy Sanderson, Gavin Andrews","doi":"10.1002/mhp.93","DOIUrl":"https://doi.org/10.1002/mhp.93","url":null,"abstract":"<p><b>Background:</b> Few studies have systematically compared the relationship between lost work productivity (work impairment) and mental disorders using population surveys.</p><p><b>Aims:</b> (1) To identify the importance of individual mental disorders and disorder co-occurrences (comorbidity) as predictors of two measures of work impairment over the past month—work loss (number of days unable to perform usual activities) and work cutback (number of days where usual activities were restricted); (2) to examine whether different types of disorder have a greater impact on work impairment in some occupations than others; (3) to determine whether work impairment in those with a disorder is related to treatment seeking.</p><p><b>Method:</b> Data were based on full-time workers identified by the Australian National Survey of Mental Health and Well-Being, a household survey of mental disorders modeled on the US National Comorbidity Survey. Diagnoses were of one-month DSM-IV affective, anxiety and substance-related disorders. Screening instruments generated likely cases of ICD-10 personality disorders. The association of disorder types and their co-occurrences with work impairment was examined using multivariate linear regression. Odds ratios determined the significance of mental disorder prevalence across occupations, and planned contrasts were used to test for differences in work impairment across occupations within disorder types. The relationship between work impairment and treatment seeking was determined for each broad diagnostic group with <i>t</i>-tests.</p><p><b>Results:</b> Depression, generalized anxiety disorder and personality disorders were predictive of work impairment after controlling for impairment due to physical disorders. Among pure and comorbid disorders, affective and comorbid anxiety–affective disorders respectively were associated with the greatest amount of work impairment. For all disorders, stronger associations were obtained for work cutback than for work loss. No relationship was found between type of occupation and the impact of different types of disorder on work impairment. Only 15% of people with any mental disorder had sought help in the past month. For any mental disorder, significantly greater work loss and work cutback was associated with treatment seeking, but comparisons within specific disorder types were not significant.</p><p><b>Discussion:</b> A substantial amount of lost productivity due to mental disorders comes from within the full-time working population. The greater impact of mental disorders on work cutback compared to work loss suggests that work cutback provides a more sensitive measure of work impairment in those with mental disorders. Work impairment was based on self-report only. While there is evidence for the reliability of self-assessed work loss days, no reliability or validity studies have been conducted for work cutback days. The low rates of treatment seeking are a major health issue for th","PeriodicalId":46381,"journal":{"name":"Journal of Mental Health Policy and Economics","volume":"3 3","pages":"139-146"},"PeriodicalIF":1.6,"publicationDate":"2001-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/mhp.93","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72169216","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
BACKGROUND: The 1990's witnessed a new wave of state and federal legislation affecting mental health insurance in the United States. Although patient advocacy groups have hailed the passage of numerous "parity" laws that require insurance coverage for mental illnesses to equal that for physical ailments, it is unclear whether this activity represents a major improvement in insurance benefits among mentally ill or significantly increases their access to care. AIMS: This paper contrasts how insurance coverage has changed among individuals with mental health problems in states with and without parity legislation. METHODS: National survey data from 1996 to 1998, subset to a panel of 1220 individuals exceeding clinical screeners for a mental health disorder. Dependent variables are change in insurance status, insurance generosity and perception of access to care. The analysis contrasts changes in dependent variables between states with and without parity legislation (a difference-in-differences analysis). RESULTS: There are no statistical significant effects of state parity; point estimates suggest that parity mandates are associated with a slightly higher number of mentally ill reporting improved insurance generosity and access to care, but also with a higher number of mentally ill losing all insurance coverage in parity states. The estimated effects are too small to be statistically significant, although the sample size is limited and the study had only good statistical power to detect large effects. DISCUSSION: At the population level, state parity legislation appears to have not had large effects on the insurance coverage of the group that was intended as the primary beneficiary of legislation. Likely reasons include the limited scope of the actual legal requirements and large numbers of mentally ill that are not covered by health insurance subject to such legislation. The results do not exclude the possibility that some subgroups experienced substantial improvements in their insurance coverage. At the population level, large effects experienced by small subgroup are diluted by groups that experienced no similar changes. However, parity legislation was not considered a minor issue by advocates and opponents and this analysis has the statistical power to detect the sizeable differences that were argued in the policy debate. IMPLICATIONS FOR HEALTH POLICIES: While state parity legislation may have improved insurance benefits for some, it appears not to have resulted in substantial improvements for the mentally ill as a whole. The results could be very different, however, if strong federal legislation were passed that has a broader scope than state legislation. IMPLICATIONS FOR RESEARCH: The parity debate provides an important reminder of how little research is available to inform policy. This study provides a crude picture, but it is far from being a conclusive evaluation. The most urgent need is for data that continue to track changes in markets an
{"title":"State parity legislation and changes in health insurance and perceived access to care among individuals with mental illness: 1996–1998","authors":"R. Sturm","doi":"10.1002/MHP.97","DOIUrl":"https://doi.org/10.1002/MHP.97","url":null,"abstract":"BACKGROUND: The 1990's witnessed a new wave of state and federal legislation affecting mental health insurance in the United States. Although patient advocacy groups have hailed the passage of numerous \"parity\" laws that require insurance coverage for mental illnesses to equal that for physical ailments, it is unclear whether this activity represents a major improvement in insurance benefits among mentally ill or significantly increases their access to care. AIMS: This paper contrasts how insurance coverage has changed among individuals with mental health problems in states with and without parity legislation. METHODS: National survey data from 1996 to 1998, subset to a panel of 1220 individuals exceeding clinical screeners for a mental health disorder. Dependent variables are change in insurance status, insurance generosity and perception of access to care. The analysis contrasts changes in dependent variables between states with and without parity legislation (a difference-in-differences analysis). RESULTS: There are no statistical significant effects of state parity; point estimates suggest that parity mandates are associated with a slightly higher number of mentally ill reporting improved insurance generosity and access to care, but also with a higher number of mentally ill losing all insurance coverage in parity states. The estimated effects are too small to be statistically significant, although the sample size is limited and the study had only good statistical power to detect large effects. DISCUSSION: At the population level, state parity legislation appears to have not had large effects on the insurance coverage of the group that was intended as the primary beneficiary of legislation. Likely reasons include the limited scope of the actual legal requirements and large numbers of mentally ill that are not covered by health insurance subject to such legislation. The results do not exclude the possibility that some subgroups experienced substantial improvements in their insurance coverage. At the population level, large effects experienced by small subgroup are diluted by groups that experienced no similar changes. However, parity legislation was not considered a minor issue by advocates and opponents and this analysis has the statistical power to detect the sizeable differences that were argued in the policy debate. IMPLICATIONS FOR HEALTH POLICIES: While state parity legislation may have improved insurance benefits for some, it appears not to have resulted in substantial improvements for the mentally ill as a whole. The results could be very different, however, if strong federal legislation were passed that has a broader scope than state legislation. IMPLICATIONS FOR RESEARCH: The parity debate provides an important reminder of how little research is available to inform policy. This study provides a crude picture, but it is far from being a conclusive evaluation. The most urgent need is for data that continue to track changes in markets an","PeriodicalId":46381,"journal":{"name":"Journal of Mental Health Policy and Economics","volume":"1 1","pages":"209-213"},"PeriodicalIF":1.6,"publicationDate":"2000-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80401395","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<div> <section> <h3> <b>Organization of care</b>:</h3> <p> Health care is provided to patients with mental disorders by the state health care facilities as well as by social help agencies. Mental health care services are provided mostly by mental health facilities and partly by primary care units. Outpatient clinics, separate for psychiatric patients and substance abusers, are the most numerous mental health care units, amounting to a total of 1120. Intermediate care facilities include 110 day hospitals, 23 community mobile teams and ten hostels. The number of hospital beds amounts to 31913, i.e. 8.3 beds per 10000 population. 80% of beds are located in mental hospitals.</p> </section> <section> <h3> <b>Trends of development</b>:</h3> <p> The trends in mental health care development are outlined in the Mental Health Programme and accompanying documents accepted by the Minister of Health and Social Welfare. The programme defines specific goals to be achieved by the year 2005 in the primary, secondary and tertiary prevention of mental disorders. In the domain of mental health care accessibility the most important goals are the following: a significant reduction in the number of beds in large mental hospitals, a marked (nearly threefold) rise in the number of beds in psychiatric wards at general hospitals and a significant increase in the number of community-based forms of care (e.g. a fourfold rise in the number of day hospitals).</p> </section> <section> <h3> <b>Financing of care</b>:</h3> <p> Before 1999, the health care system was financed from the state budget and the health care spendings were subject to a political auction each year. Allocation of funds among hospitals and health care centres was based on the total previous year budgetary spendings of particular facilities and did not take into account a detailed cost analysis. Such a financing approach, although giving a feeling of a relative financial safety, did not encourage health care facilities to introduce an organizational flexibility and to expand the scope of their services. In psychiatry, it manifested itself in a very slow development of some community psychiatry forms (mostly day hospitals, mobile community teams and hostels). The Health Care Institutions Act has created a legal framework for the financial management of health care units in their new, independent form. Conditions for health care financing through regional sickness funds were thus created. The financing is currently based on contracts made by sickness funds with health care facilities for specific health services. Both the quantity and price of services should be mutually negotiated.</p> <p>Some simplified measures of services offered were us
{"title":"Organization and financing of mental health care in Poland","authors":"Wanda Langiewicz, Elzbieta Slupczynska-Kossobudzka","doi":"10.1002/1099-176X(200006)3:2<77::AID-MHP79>3.0.CO;2-S","DOIUrl":"https://doi.org/10.1002/1099-176X(200006)3:2<77::AID-MHP79>3.0.CO;2-S","url":null,"abstract":"<div>\u0000 \u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> <b>Organization of care</b>:</h3>\u0000 \u0000 <p> Health care is provided to patients with mental disorders by the state health care facilities as well as by social help agencies. Mental health care services are provided mostly by mental health facilities and partly by primary care units. Outpatient clinics, separate for psychiatric patients and substance abusers, are the most numerous mental health care units, amounting to a total of 1120. Intermediate care facilities include 110 day hospitals, 23 community mobile teams and ten hostels. The number of hospital beds amounts to 31913, i.e. 8.3 beds per 10000 population. 80% of beds are located in mental hospitals.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> <b>Trends of development</b>:</h3>\u0000 \u0000 <p> The trends in mental health care development are outlined in the Mental Health Programme and accompanying documents accepted by the Minister of Health and Social Welfare. The programme defines specific goals to be achieved by the year 2005 in the primary, secondary and tertiary prevention of mental disorders. In the domain of mental health care accessibility the most important goals are the following: a significant reduction in the number of beds in large mental hospitals, a marked (nearly threefold) rise in the number of beds in psychiatric wards at general hospitals and a significant increase in the number of community-based forms of care (e.g. a fourfold rise in the number of day hospitals).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> <b>Financing of care</b>:</h3>\u0000 \u0000 <p> Before 1999, the health care system was financed from the state budget and the health care spendings were subject to a political auction each year. Allocation of funds among hospitals and health care centres was based on the total previous year budgetary spendings of particular facilities and did not take into account a detailed cost analysis. Such a financing approach, although giving a feeling of a relative financial safety, did not encourage health care facilities to introduce an organizational flexibility and to expand the scope of their services. In psychiatry, it manifested itself in a very slow development of some community psychiatry forms (mostly day hospitals, mobile community teams and hostels). The Health Care Institutions Act has created a legal framework for the financial management of health care units in their new, independent form. Conditions for health care financing through regional sickness funds were thus created. The financing is currently based on contracts made by sickness funds with health care facilities for specific health services. Both the quantity and price of services should be mutually negotiated.</p>\u0000 \u0000 <p>Some simplified measures of services offered were us","PeriodicalId":46381,"journal":{"name":"Journal of Mental Health Policy and Economics","volume":"3 2","pages":"77-81"},"PeriodicalIF":1.6,"publicationDate":"2000-11-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/1099-176X(200006)3:2<77::AID-MHP79>3.0.CO;2-S","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72162502","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2000-11-23DOI: 10.1002/1099-176X(200006)3:2<83::AID-MHP81>3.0.CO;2-F
David S. Salkever, Judith A. Shinogle
<div> <section> <h3> <b>Background and Aims of Study</b>:</h3> <p> The use of specialized behavioral health companies to manage mental/health benefits has become widespread in recent years. Recent studies have reported on the cost and utilization impacts of behavioral health carve-outs. Yet little previous research has examined the factors which lead employer-based health plans to adopt a carve-out strategy for mental health benefits. The examination of these factors is the main focus of our study. Our empirical analysis is also intended to explore several hypotheses (moral hazard, adverse selection, economies of scale and alternate utilization management strategies) that have recently been advanced to explain the popularity of carve-outs.</p> </section> <section> <h3> <b>Methods</b>:</h3> <p> The data for this study are from a survey of employers who have long-term disability contracts with one large insurer. The analysis uses data from 248 employers who offer mental health benefits combined with local market information (e.g. health care price proxies, state tax rates etc), state regulations (mental health and substance abuse mandate and parity laws) and employee characteristics. Two different measures of carve-out use were used as dependent variables in the analysis: (1) the fraction of health plans offered by the employer that contained carve-out provisions and (2) a dichotomous indicator for those employers who included a carve-out arrangement in all the health plans they offered.</p> </section> <section> <h3> <b>Results</b>:</h3> <p> Our results tended to support the general cost-control hypothesis that factors associated with higher use and/or costs of mental health services increase the demand for carve-outs. Our results gave less consistent support to the argument that carve-outs are demanded to control adverse selection, though only a few variables provided a direct test of this hypothesis. The role of economies of scale (i.e., group size) and the effectiveness of alternative strategies for managing moral hazard costs (i.e., HMOs) were confirmed by our results.</p> </section> <section> <h3> <b>Discussion</b>:</h3> <p> We considered a number of different hypotheses concerning employers' demands for mental health carve-outs and found varying degrees of support for these hypotheses in our data. Our results tended to support the general cost-control hypothesis that factors associated with higher use and/or costs of mental health services increase the demand for carve-outs.</p> </section> <section> <h3> <b>Limitations</b>:</h3> <p> Our
{"title":"Empirical evidence on the demand for carve-outs in employment group mental health coverage","authors":"David S. Salkever, Judith A. Shinogle","doi":"10.1002/1099-176X(200006)3:2<83::AID-MHP81>3.0.CO;2-F","DOIUrl":"https://doi.org/10.1002/1099-176X(200006)3:2<83::AID-MHP81>3.0.CO;2-F","url":null,"abstract":"<div>\u0000 \u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> <b>Background and Aims of Study</b>:</h3>\u0000 \u0000 <p> The use of specialized behavioral health companies to manage mental/health benefits has become widespread in recent years. Recent studies have reported on the cost and utilization impacts of behavioral health carve-outs. Yet little previous research has examined the factors which lead employer-based health plans to adopt a carve-out strategy for mental health benefits. The examination of these factors is the main focus of our study. Our empirical analysis is also intended to explore several hypotheses (moral hazard, adverse selection, economies of scale and alternate utilization management strategies) that have recently been advanced to explain the popularity of carve-outs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> <b>Methods</b>:</h3>\u0000 \u0000 <p> The data for this study are from a survey of employers who have long-term disability contracts with one large insurer. The analysis uses data from 248 employers who offer mental health benefits combined with local market information (e.g. health care price proxies, state tax rates etc), state regulations (mental health and substance abuse mandate and parity laws) and employee characteristics. Two different measures of carve-out use were used as dependent variables in the analysis: (1) the fraction of health plans offered by the employer that contained carve-out provisions and (2) a dichotomous indicator for those employers who included a carve-out arrangement in all the health plans they offered.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> <b>Results</b>:</h3>\u0000 \u0000 <p> Our results tended to support the general cost-control hypothesis that factors associated with higher use and/or costs of mental health services increase the demand for carve-outs. Our results gave less consistent support to the argument that carve-outs are demanded to control adverse selection, though only a few variables provided a direct test of this hypothesis. The role of economies of scale (i.e., group size) and the effectiveness of alternative strategies for managing moral hazard costs (i.e., HMOs) were confirmed by our results.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> <b>Discussion</b>:</h3>\u0000 \u0000 <p> We considered a number of different hypotheses concerning employers' demands for mental health carve-outs and found varying degrees of support for these hypotheses in our data. Our results tended to support the general cost-control hypothesis that factors associated with higher use and/or costs of mental health services increase the demand for carve-outs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> <b>Limitations</b>:</h3>\u0000 \u0000 <p> Our ","PeriodicalId":46381,"journal":{"name":"Journal of Mental Health Policy and Economics","volume":"3 2","pages":"83-95"},"PeriodicalIF":1.6,"publicationDate":"2000-11-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/1099-176X(200006)3:2<83::AID-MHP81>3.0.CO;2-F","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72127422","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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