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Discussions of health care delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient-Centered Medical Home, the Health Home initiative within Medicaid, and the Accountable Care Organization. To incorporate behavioral health into health reform, policymakers and practitioners may consider embedding in the reform efforts explicit tools-accountability measures and payment designs-to improve access to and quality of care for patients with behavioral health needs. [ABSTRACT FROM AUTHOR]

This paper reviews current models, research, and approaches to improving care on the primary care/behavioral health interface in the USA. We focus on care in the public sector where high rates of comorbidity, regulatory burdens, and lack of resources create particular challenges to collaboration and coordination. To achieve the goals of improved coordination and collaboration, it will be critical to address key financing, workforce, information technology, performance assessment, and research issues. It will also be critical to engage multiple stakeholders including consumers, mental health and health providers, and policymakers and public sector funders. [ABSTRACT FROM AUTHOR]

Mental health clinicians rely on a range of legal mandates and interpersonal strategies of encouragement and pressure to address nonadherence to treatment. This paper describes the development and testing of a scale to assess formal and informal strategies used by clinicians to encourage adherence to medication. The 16-item measure was administered to 271 clinicians and analyzed using Rasch measurement modeling. Subsequently, items were revised and readministered to a second sample of 44 clinicians in an urban mental health clinic. Rasch analysis of the items yielded a coherent and internally consistent unidimensional measure of strategies used to promote adherence that vary on a continuum of pressure or social control. Criterion-related validity was assessed by observing the association of the measure with clinician ratings of client adherence. The resulting measure may be employed in future studies to examine the ways in which clinician behavior relates to medication adherence and to consumer perceptions of treatment alliance, quality of care, and perceived coercion. [ABSTRACT FROM AUTHOR]

Universal substance use screening in primary care can proactively identify patients for intervention, though implementation is challenging. This project developed a strategy for universal low time- and labor-cost screening, brief intervention, and referral for treatment (SBIRT) in an HIV primary care clinic at an academic medical center in the Southeastern USA. Screening was implemented using a tablet computer that calculated results in real time and suggested motivational language for provider response. A brief intervention (BNI) was conducted by a trained professional as needed, preventing the need for all clinic providers to be competent in motivational interviewing (MI). More than 1868 patients were screened in 12 months, with an MI intervention conducted for 101 patients with higher risk use. Forty-four patients were referred for in-clinic treatment, compared to nine in the previous year. Computer-based, self-administered screening with real-time linkage to a BNI can allow recommended screening with low provider burden. [ABSTRACT FROM AUTHOR]

The Collaborative Initiative to Help End Chronic Homelessness was a coordinated effort by the US Departments of Health and Human Services (HHS), Housing and Urban Development (HUD), and Veterans Affairs (VA), and the US Interagency Council on Homelessness to house and provide comprehensive supportive services to individuals with serious psychiatric, substance use, health, and related disabilities who were experiencing long-term chronic homelessness. Eleven communities received 3-year grants from HHS and VA (2003–2006) and up to 5-year grants from HUD (2003–2008) to implement the initiative. This article provides background on chronic homelessness, describes the federal collaboration to comprehensively address chronic homelessness, and introduces the seven articles in this special issue that describe the findings and lessons learned from the participating communities in addressing chronic homelessness. Collectively, these articles offer insight into the challenges and benefits of providing housing and services to individuals experiencing chronic homelessness. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic presents a crisis of mental health in the United States (U.S.) alongside a crisis of infectious disease. Racial inequities in COVID-19 morbidity and mortality have brought health equity to the forefront of public health policy, exacerbating prior inequities in mental health care access and outcomes. This Commentary asserts that policymakers and advocates must prioritize mental health when responding to the pandemic. While the pandemic is an emergency of unprecedented scale, the authors argue that it also is an opportunity to implement broad-based mental health policy reforms in the U.S. that build on the successes of the Affordable Care Act and the Mental Health Parity and Addiction Equity Act. Guided by innovative state and local policies to promote population-level mental health, we outline a series of empirically grounded strategies for federal and state policymakers to promote mental health equity in the wake of COVID-19. [ABSTRACT FROM AUTHOR]

The US government funds integrated care demonstration projects to decrease health disparities for individuals with serious mental illness. Drawing on the Exploration Preparation Implementation Sustainability (EPIS) implementation framework, this case study of a community mental health clinic describes implementation barriers and sustainability challenges with grant-funded integrated care. Findings demonstrate that integrated care practices evolve during implementation and the following factors influenced sustainability: workforce rigidity, intervention clarity, policy and funding congruence between the agency and state/federal regulations, on-going support and training in practice application, and professional institutions. Implementation strategies for primary care integration within CMHCs include creating a flexible workforce, shared definition of integrated care, policy and funding congruence, and on-going support and training. [ABSTRACT FROM AUTHOR]

Young adults experiencing first-episode psychosis have historically been difficult to retain in mental health treatment. Communities across the United States are implementing Coordinated Specialty Care to improve outcomes for individuals experiencing first-episode psychosis. This mixed-methods research study examined the relationship between program services and treatment retention, operationalized as the likelihood of remaining in the program for 9 months or more. In the adjusted analysis, male gender and participation in home-based cognitive behavioral therapy were associated with an increased likelihood of remaining in treatment. The key informant interview findings suggest the shared decision-making process and the breadth, flexibility, and focus on functional recovery of the home-based cognitive behavioral therapy intervention may have positively influenced treatment retention. These findings suggest the use of shared decision-making and improved access to home-based cognitive behavioral therapy for first-episode psychosis patients may improve outcomes for this vulnerable population. [ABSTRACT FROM AUTHOR]

The National Institutes of Health, Office of Disease Prevention, has described polycystic ovary syndrome (PCOS) as a major public health problem for women in the USA. This study examines the suitability of the National Health Care Surveys, collected by the Centers for Disease Control and Prevention, to understand patient demographics and behavioral health services associated with PCOS-related medical visits. Data were from the 2005-2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. PCOS-related medical visits were identified using the International Classification of Diseases, 9th Revision, Clinical Modification code 256.4. Items on mental health and health education ordered or provided did not meet the National Center for Health Statistics criteria necessary to produce reliable national estimates (i.e., at least 30 unweighted records and a relative standard error <30%). Findings underscore the need to strengthen national surveillance to further understand behavioral health care for patients with PCOS. [ABSTRACT FROM AUTHOR]

How are characteristics of communities associated with the implementation of the principles of systems of care (SOC)? This study uses multilevel modeling with a stratified random sample ( N = 225) of US counties to explore community-level predictors of the implementation factors of the System of Care Implementation Survey. A model composed of community-level social indicators fits well with 5 of 14 factors identified as relevant for effective SOCs. As hypothesized, community disadvantage was negatively and residential stability positively associated with the implementation of SOC principles. Designation as a mental health professional shortage area was positively related to some implementation scores, as was the percentage of minority residents, while rurality was not significantly associated with any of the factors. Given the limitations of the study, the results should be interpreted with caution, but suggest that further research is merited to clarify these relationships that could inform efforts directed at promoting SOCs. [ABSTRACT FROM AUTHOR]

The purpose of this study was to explore the structure, process, and outcomes of emergency department (ED) psychiatric services that are available to children who present with behavioral health problems. The author designed and employed a 33-item survey for data collection. All nonfederal EDs in one southeastern state ( N = 68) were solicited to participate. Descriptive analyses including ANOVAs, t tests, and chi-squares summarized sample characteristics and group differences by ED pediatric psychiatric service (EDPPS) arrangement. Thirty-four hospitals participated, sharing similar organizational characteristics with nonresponders except that participating hospitals were significantly more likely to have inpatient psychiatric services. The survey successfully captured data confirming that EDs use a range of strategies to manage children with behavioral health problems, raising concerns about the suitability of such service variation. These results highlight the need for further research that examines the association of EDPPS structure and process with patient and organizational outcomes to inform quality improvements in pediatric behavioral healthcare. [ABSTRACT FROM AUTHOR]

Data from the Substance Abuse and Mental Health Services Administration’s Integrated Database (IDB) were used to examine the service use patterns of individuals with possible opiate use disorders in Washington State. Results indicate that regardless of Medicaid enrollment status, individuals who received mental health (MH) or substance abuse (SA) services only through state agencies received no inpatient substance abuse service. Furthermore, when compared with individuals who received at least one MH/SA service through Medicaid, those who received services only through the state agencies were less likely to have received any MH services and were more likely to have received residential SA services. This analysis highlights the importance of using integrated client data in providing a more comprehensive understanding of services to inform policy and raises significant questions about how regulatory requirements affecting different funding mechanisms might drive settings of care in ways not related to the care needed. [ABSTRACT FROM AUTHOR]

Data drawn from the Mercer National Survey of Employer-sponsored Health Plans in 1997 and 2003 indicate that a large majority of employers continue to provide some level of coverage for mental health (MH) services in their primary plans. However, a majority of plans continue to impose different benefit limitations for MH than for other medical treatment. Among plans with limitations on MH coverage, there was a sharp increase in the use of limits on inpatient days and outpatient visits between 1997 and 2003. The proportion of employers providing coverage for some MH services decreased; e.g., among small employers, 88% provided coverage for inpatient MH care in 2003, compared with 94% in 1997. These results suggest that parity legislation has had a noticeable but limited effect, but that, at least in the short-term, it is unlikely that universal parity in employer-based plans will be achieved through a legislative strategy. [ABSTRACT FROM AUTHOR]

This article presents estimates of the proportion of the U.S. population that had mental health benefits in 1999, of the extent of their coverage, and of the proportion that were enrolled in health plans subject to the Mental Health Parity Act of 1996 (MHPA). Findings indicate that over three-quarters (76%) of the U.S. population had mental health benefits as part of their health insurance. Approximately 18% of the population had no mental health benefits, and for the remaining 6%, mental health benefits could not be determined. Of the 18% with no mental health benefits, most (84%) had no health insurance whatsoever, while the remainder (16%) had health insurance that did not cover mental health benefits. Estimates of the generosity of coverage indicate that 44% of the population had benefits that included prescription drugs, and that provided at least 30 inpatient days and 20 outpatient visits for psychiatric care. For 12% of the population, benefit generosity could not be determined. Finally, study results suggest that the MHPA affected only 42% of the U.S. population. [ABSTRACT FROM AUTHOR]

This study examines 1999 data from Medstat's MarketScan database of privately insured employees of US firms and their dependents. Of enrolled children and adolescents ages 2-18, 6.6% had claims for mental health services. Average outpatient expenditures per user were $651. Of children/adolescents with claims for mental health services (MH claimants), 3.4% had inpatient MH services, with an average length of stay of 8.9 days and average MH-related inpatient expenditure per user of $7,048. One half of MH claimants who had pharmacy benefit data had claims for psychotropic medications, with average expenditures per user of $328. Whereas children/adolescent mental health users comprised 8.3% of all service users, expenditures for their care were 20.5% of all service expenditures for children/adolescents in private health plans. Results also highlight the importance of including data on psychotropic medication in analysis of children's MH services utilization, as well as the need to consider the use of psychotropic medications among children/adolescents who do not utilize other MH services. [ABSTRACT FROM AUTHOR]

This study provides information about the extent of comorbidity between medical and behavioral problems among adolescents in mental health services, describes the clinical and sociodemographic characteristics of adolescents with both problems, and discusses the consequences or comorbidity for service delivery. Nationally representative mental health service use data for adolescents (age 12-17) in inpatient, outpatient, and residential mental health service settings (weighted N=296,755) were used. Close to one fifth (18.9%) of the adolescents had a medical problem, and adolescents with anxiety and pervasive developmental disorders had the highest rates of medical problems. In multivariate logistic regressions, having a medical problem significantly increased the odds of serious functional impairment; having a secondary or dual psychiatric diagnosis was only significant in interaction with a medical problem. The results underscore the need for adolescent behavioral health research and practice to attend to multiple influences on functioning. [ABSTRACT FROM AUTHOR]

The field of mental health has long suffered from a lack of convergence of disciplines that deal with the mind, the brain, and behavior. This mind-brain dualism has been particularly detrimental for consumers and their families who daily face stigma and discrimination. The understanding of the brain and its dysfunctions has benefited from the study of the human genome and, in particular, of the mutations and variations in its code. This analysis permits a better understanding of the biological basis of mental disease and will soon inform a generation of new diagnostic tools and individualized pharmacological therapies. A biological perspective on mental illness will be complemented by the analysis of the social factors influencing people's behavior and their impact on brain biology and gene function. Neurobiology has progressed to a level for which the knowledge that is generated, even if still colored with uncertainty, could represent a catalyst for the creation of an alliance between neuroscientists and consumers. This partnership has the potential to benefit both parties but will require some concrete steps that might be outside of the usual courses of action for both consumers and scientists. It is by building collaborations based on personal contact and information sharing that a transformation of the mental health care system can occur. [ABSTRACT FROM AUTHOR]

This study examines the validity, utility, and costs of using a brief telephone-administered instrument, the Brief Health Services Questionnaire (BHSQ), for self-reported health care provider contacts relative to collection and abstraction of complete medical records. The study sample was 441 community-dwelling at-risk drinkers who participated in an 18-month longitudinal study. Agreement between BHSQ self-reports and abstracted provider contacts was good to very good for general medical (79% agreement, kappa = .50) and specialty mental health contacts (93% agreement, kappa = .62), but low for "other" miscellaneous health contacts (61% agreement, kappa = .04). Average cost to collect and abstract complete medical records was 424 US dollars per study participant, whereas average cost to administer only the BHSQ was 31 US dollars per participant. Although it is not possible to conduct a formal cost-effectiveness analysis, results suggest the BHSQ is a viable option for collecting self-reported health provider contacts in a sample of at-risk drinkers, with definite cost advantages over more elaborate data collection methods. [ABSTRACT FROM AUTHOR]

This study examined familiarity, perceived effectiveness, and implementation of evidence-based treatments for children in community settings. A sample of service providers in agencies affiliated with federal programs to improve children's mental health services was identified using a snowball sampling procedure. Forty-four percent of the sample (n = 616) responded to a Web-based survey designed to collect data on evidence-based treatments. High familiarity with, relatively high-perceived effectiveness, and generally high use of evidence-based treatments were reported. Partial implementation of treatment protocols within the context of few agency mandates and widely ranging supports for the implementation of evidence-based treatments was found. Results support the inclusion of more complex models of diffusion, dissemination and implementation in research, and development efforts for evidence-based treatments. [ABSTRACT FROM AUTHOR]

Historically, children of parents with co-occurring substance abuse and mental health disorders and histories of violence/trauma have been overlooked in behavioral health treatment systems. The Women, Co-occurring Disorders and Violence Study (WCDVS) was a 5-year initiative funded by the United States Substance Abuse and Mental Health Services Administration (SAMHSA) that included a Children's Study that explored the treatment needs of children of women with these multiple disorders. This article describes the development of the Children's Study intervention that included clinical assessment, group intervention, and resource coordination/advocacy for children aged 5-10 to build resilience through increasing coping skills, improving interpersonal relationships, and helping coalesce positive identity and self-esteem. Innovative procedures, including the participation of consumer/survivor/recovering women and mothers, in the planning, implementation, and administrative applications of this intervention and study are also highlighted. It is recommended that programs begin to implement family-focused integrated treatment approaches that can potentially increase protective factors for children affected by parental mental illness, substance abuse, and violence. [ABSTRACT FROM AUTHOR]

A pre-post study design was used to look at changes in behavioral health care services and costs for Medicaid-eligible individuals with schizophrenia in a managed care (MC) carve-out compared to a fee-for-service (FFS) program in Pennsylvania between 1995 and 1998. Statistically significant reductions of 59% were found in hospital expenditures in the MC program compared to 18.3% in the FFS program. The decline in hospital costs was due to dramatic fee reductions in the MC site. No significant differences in overall ambulatory utilization were found in either program; however, ambulatory expenditures rose 57% in the MC program versus a decline of 11% in fee for service. The ambulatory cost increase resulted from a cost shift between county block grant funds, and Medicaid funds, with no additional revenues provided to outpatient providers. Study implications are that cost reductions from MC are mainly due to reducing utilization and payments to hospitals, similar to the findings for private sector programs. [ABSTRACT FROM AUTHOR]

Problems related to mental illness are increasingly becoming the focal point of public concern over the safety and performance of schools, yet little is known about the availability and quality of school-based mental health services in the United States. In this article it is estimated that approximately 50% of US middle and high schools have any mental health counseling services available on-site and approximately 11% have mental health counseling, physical examinations, and substance abuse counseling available on-site. There are substantial differences in mental health counseling availability by region, urbanicity, and school size, with rural schools, schools in the Midwest and South regions, and small schools being least likely to offer mental health counseling. Multivariate estimates suggest that disparities between schools in the availability of mental health counseling and related health services may be partly explained by differences in access to Medicaid for financing of health services provided at school. [ABSTRACT FROM AUTHOR]

Despite growing interest in assessment of program implementation, little is known about the best way to evaluate whether a particular program has implemented the intended service to a level that is minimally acceptable to a funding source, such as a state mental health authority. Such is the case for assertive community treatment (ACT), an evidence-based practice being widely disseminated. Using an exploratory, actuarial approach to defining program standards, this study applies different statistical criteria for determining whether or not a program meets ACT standards using the 28-item Dartmouth Assertive Community Treatment Scale. The sample consists of 51 ACT programs, 25 intensive case management programs, and 11 brokered case management programs which were compared to identify levels of fidelity that discriminated between programs, but were still attainable by the majority of ACT programs. A grading system based on mean total score for a reduced set of 21 items appeared to be most attainable, but still discriminated ACT programs from other forms of case management. Implications for setting and evaluating ACT program standards are discussed. [ABSTRACT FROM AUTHOR]

This study examined the effect of different Medicaid insurance plans on children's mental health service use through survey, claims, and encounter data collected between February 1998 and February 1999. Participants were assigned to 1 of 3 insurance plans: fee-for-service, a Health Maintenance Organization and a prepaid carve-out. Logistic and stratified logistic regression were used to examine the effect of plan on service utilization, adjusting for caregiver report of need for services and psychosocial functioning. There was no difference in service use by plan controlling for demographic characteristics; however, when psychopathology and caregiver report of need for services were included in the model, the odds of using services in the Health Maintenance Organization was half of and the odds in the carve-out 29% less than the odds of using services in fee-for-service. Characteristics of the interaction between need, psychopathology, and insurance plan that may be associated with the reduction in service use are discussed. [ABSTRACT FROM AUTHOR]

The adequacy of risk adjustment to eliminate incentives for managed care organizations (MCOs) to avoid enrolling costly patients had been questioned. This study explored systematic differences in expenditures between beneficiaries with and without substance disorders assigned to the same capitation rate group under the Maryland Medicaid HealthChoice program. The investigators used fiscal year (FY) 1995 to 1997 Medicaid data to assign beneficiaries to rate cells based on FY 1995 diagnoses and compared the distribution of expenditures for beneficiaries with and without substance disorders, defined using FY 1997 and FY 1995 diagnoses. Results showed that differences in FY 1997 expenditures between beneficiaries with and without FY 1995 substance disorders were negligible. However, MCOs could expect greater average losses and lower average profits on beneficiaries with FY 1997 substance disorders. Thus, the adjusted clinical groups methodology used to adjust capitation payments in the HealthChoice program attenuated, but did not eliminate, financial incentives for MCOs to avoid substance abusers. [ABSTRACT FROM AUTHOR]

This study evaluates the impact of Nebraska's Medicaid managed care program for behavioral health services on mental health service utilization, expenditures, and quality of care. Implementation of the program is correlated with progressive reductions in both total (about 13% over 3 years) and per eligible per month (20%) expenditures and a rapid, extensive decline in inpatient utilization and admissions. The percentage of enrollees receiving any type of treatment for a mental disorder actually increased modestly. Most important, several indicators of quality of care (e.g., timely receipt of ambulatory care following discharge from inpatient care and readmission to inpatient care shortly following discharge) suggest that quality of care did not materially change under the carve-out. Although a thorough assessment of quality of care impacts is warranted, this study suggests implementation of a managed care program may allow states to reduce Medicaid expenditures without compromising quality of care. [ABSTRACT FROM AUTHOR]

This article describes a model for integrating psychiatric rehabilitation services in a managed behavioral health care structure. Psychiatric rehabilitation and managed care are two distinct developments in the provision of mental health services that have proceeded independently though they can have compatible methods and outcomes. Descriptive detail is provided about a state initiative in Iowa to provide psychiatric rehabilitation services to those with serious mental illness through the state-contracted managed behavioral health care corporation. The article describes factors leading to the program's implementation, service delivery structures, reimbursements, personnel requirements, and performance indicators. Evidence for supporting this innovation is provided through a case-controlled outcomes study of mental health service units used and their costs for participants and matched controls. [ABSTRACT FROM AUTHOR]

The waiting list is commonly used in the delivery of mental health services. Despite their prevalence, their design and management are generally not standardized; rather, they take place on an ad hoc basis as a response to undesirable circumstances. The formulation and management of a waiting list initially appear to be simple, straightforward, and benign. However, on close examination, waiting lists are complicated, and implementation involves pervasive costs and benefits. This article delineates the costs and benefits involved in the use of waiting lists. It outlines administrative, clinical, and ethical issues intrinsic in the use of waiting lists and provides recommendations aimed at assisting in their design and management. While recommendations encompassing the range of possible unique situations are impractical, guidelines for consideration of important variables are provided. [ABSTRACT FROM AUTHOR]

No recent national data on expenditures and utilization are available to provide a benchmark for reform of mental health systems for children and adolescents. The most recent estimates, from 1986, predate the dramatic growth of managed care. This study provides updated national estimates. Treatment expenditures are estimated to be $11.68 billion ($172 per child). Adolescents have the highest expenditures at $293 per child followed by $163 per child aged 6 to 11 and $35 per preschool-aged child. Outpatient services account for 57%, inpatient for 33%, and psychotropic medications for 9% of the total. Unlike earlier reports, outpatient care now accounts for the majority of expenditures. This finding replicates the differences between recent managed care data and earlier actuarial databases for privately insured adults and confirms the trend from inpatient toward outpatient care. [ABSTRACT FROM AUTHOR]

This article describes a study evaluating the Consumer Assessment of Behavioral Health Survey (CABHS) and the Mental Health Statistics Improvement Program (MHSIP) surveys. The purpose of the study was to provide data that could be used to develop recommendations for an improved instrument. Subjects were 3,443 adults in six behavioral health plans. The surveys did not differ significantly in response rate or consumer burden. Both surveys reliably assessed access to treatment and aspects of appropriateness and quality. The CABHS survey reliably assessed features of the insurance plan; the MHSIP survey reliably assessed treatment outcome. Analyses of comparable items suggested which survey items had greater validity. Results are discussed in terms of consistency with earlier research using these and other consumer surveys. Implications and recommendations for survey development, quality improvement, and national policy initiatives to evaluate health plan performance are presented. [ABSTRACT FROM AUTHOR]

General and private psychiatric hospitals are becoming increasingly common as sites for involuntary hospitalization. Unlike the public facilities that these settings are supplanting, these hospitals must pay strict attention to issues associated with reimbursement, insurance status, and managed care. This article examines the effects of insurance status on length of stay for involuntarily hospitalized patients in general and private hospitals in Massachusetts. Using a two-stage sampling procedure, data on episodes of involuntary hospitalization were gathered and assessed using multiple regression. The primary effect was found between patients with Medicare, who had the longest stays, and individuals who were uninsured, who had the shortest. The data raise concerns that warrant closer scrutiny on the part of administrators and clinicians. [ABSTRACT FROM AUTHOR]

Two consortia of community mental health centers in Colorado varied in their administrative readiness for changing to a capitated system and, ultimately, implemented capitation using different organizational arrangements. The objective was to assess the impact of this natural experiment on administrative change, costs, and utilization of services during the first two years postcapitation. Prior to capitation, one was rated as having greater "readiness" than the other and received a capitation contract from the state, while the other did not. A private, for-profit managed behavioral health organization was awarded a contract and formed a joint venture with the less "ready" consortium, providing managed care expertise to complement the consortium's expertise in delivering mental health services. Two years later, these consortia do not look different either administratively or in their patterns of service utilization and costs. These findings suggest alternative ways of successfully implementing a capitated public mental health system. [ABSTRACT FROM AUTHOR]

Eighty-five adults seeking mental health assistance six months after the Oklahoma City bombing were assessed to determine which of three groups of variables (exposure, peri-traumatic responses, and social support) predicted development of post-traumatic stress disorder (PTSD) symptoms. Variables most highly associated with subsequent PTSD symptoms included having been injured (among exposure variables), feeling nervous or afraid (peri-traumatic responses), and responding that counseling helped (support variables). Combining primary predictors in the three areas, PTSD symptoms were more likely to occur in those reporting counseling to help and those feeling nervous or afraid at the time of the bombing. Implications of these findings are discussed for behavioral health administrators and clinicians planning service delivery to groups of victims seeking mental health intervention after terrorist attacks and other disasters. [ABSTRACT FROM AUTHOR]

Not until 1989 did the Red Cross officially recognize a need for a systematic and organized plan for the mental health needs of disaster survivors. Over the next decade, the Red Cross Disaster Mental Health Services program has developed and evolved to assist both disaster victims and the Red Cross workers who serve them to cope with the overwhelming stresses encountered by both groups in the aftermath of disasters. The Red Cross now coordinates a large and diverse group of mental health professionals from fields of psychology, psychiatry, nursing, social work, marriage and family therapy, and counseling who work together cooperatively. Cross-disciplinary conflicts are minimized by the Red Cross' generic approach to the various mental health professional specialties as functionally interchangeable in performing Red Cross duties. This article reviews the development of this process and describes one local Red Cross chapter's early experience as part of this effort. [ABSTRACT FROM AUTHOR]

Many U.S. employers have carved substance abuse and mental health services out of their medical plans, changing the way millions of people access care. Employers that take this approach contract directly with specialized vendors, bypassing their general health plans. Since carving out may alter access and treatment, there is a need to understand why employers take this approach. This article reviews various hypotheses about why purchasers carve out and tests them using data from a survey of America's largest employers, the Fortune 500 firms. Size is the strongest predictor of an employer's decision to carve out behavioral health once other characteristics are controlled for. Employers that report they value coordination are less likely to carve out, while those that value special expertise are more likely to carve out. Employers are less likely to carve out enrollees in health maintenance organizations (HMOs) than those in other types of plans. [ABSTRACT FROM AUTHOR]

This article compares provider perceptions of access to services and utilization management (UM) procedures in two Medicaid programs in the same state: a full-risk capitated managed care (MC) program and a no-risk, fee-for-service (FFS) program. Survey data were obtained from 198 mental health clinicians and administrators. The only difference found between respondents in the FFS and MC sites was that outpatient providers in the MC site reported significantly lower levels of access to high-intensity services than did providers in the FFS site (p < .001). Respondents in the two sites reported similar attitudes toward UM procedures, including a strong preference for internal over external UM procedures. These findings support the conclusion that through diffusion of UM procedures, all care in the Medicaid program for persons with a serious mental illness is managed, regardless of risk arrangement. Implications for mental health services and further research are discussed. [ABSTRACT FROM AUTHOR]

In 1995, the state of Colorado began a new funding program for the provision of mental health services to Medicaid recipients. Medicaid funding was restructured from a fee-for-service system into a capitated managed care system. The restructuring altered the way in which mental health resources were allocated within Colorado's mental health system. This article explores the ethical principles inherent in the allocation of mental health resources within Colorado. The allocation system before and after the capitation pilot is analyzed according to three models of distributive justice. Under capitation, access to care corresponds to egalitarian ideals, while service delivery and outcomes follow a more utilitarian philosophy. Results from several empirical studies of the Colorado Medicaid system are used to support this ethical analysis. The analysis leads to the suggestion that the fair-opportunity rule may be a useful principle for developing just distribution systems in other states in the future. [ABSTRACT FROM AUTHOR]

Los Angeles PARTNERS, or "people achieving rehabilitation together need empowering respectful support," is a treatment program that uses capitation to shift risk for treatment costs of high utilizers of public mental health services to private community-based treatment organizations. This analysis reveals two important findings from PARTNERS. First, the economic incentives created by capitation contributed to the dis-enrollment of PARTNERS clients; furthermore, factors such as not speaking English or Spanish or having schizophrenia increased the probability of dis-enrollment. Second, analyses of health costs for enrollees in the PARTNERS capitation program suggest that the program did not result in a change in total costs. However, the program increased the use of community-based care and increased treatment costs for clients with lower preprogram costs but decreased costs for the clients with high preprogram costs. These results suggest that future capitation programs for this severely ill population would benefit from using detailed clinical information to determine program eligibility and to set risk-adjusted capitation rates. [ABSTRACT FROM AUTHOR]

This study reports estimates of the preclosure and postclosure costs of mental health services for patients directly affected by the closing of Central State Hospital. The data come from state budget documents and from the billing records of the community mental health centers serving the discharged clients. On average, it cost Indiana approximately $68,347 (in 1995 dollars) to provide 12 months of state hospital care for this client cohort in fiscal year 1993. In contrast, during the first year following the closure, the average per patient cost to the state was $55,417. When clients were served exclusively in community care settings, the average annual per patient cost was $40,618. The analyses suggest that the closing reduced the costs of caring for this cohort of patients by approximately 18.9%. A significant portion of the cost savings to the state mental health budget was achieved by shifting some of the direct patient care costs to Medicaid/Medicare. [ABSTRACT FROM AUTHOR]

This study examines the effects of a mental health carve-out on a sample of continuously enrolled employees (N = 1,943) over a four-year time frame (1990-1994). The article presents a health care services utilization model of the effect of the carve-out on outpatient mental health use, cost, and source of payment in the three years post implementation relative to the year prior to the carve-out model. In the first three years of the carve-out, the likelihood of employees seeking mental health care increased in significant part because of the carve-out. For the outpatient mental health services user, the carve-out was not associated with the level of mental health services received. The carve-out was significantly associated over time with a reduction in the patient's and employer's mental health costs. This effect was more pronounced in the second and third years of the carve-out. The article explores the policy implications of these and other findings. [ABSTRACT FROM AUTHOR]

Describes a children's managed mental health care program that incorporates both a family participation service model and a family-initiated evaluation model. Family partnership service and evaluation model; Best practice model in the public mental health system in King County, Washington; Implications for mental health services.

This article introduces the trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) closing studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community-based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple-stakeholder study of the closing of a state-run, long-term care facility in Indiana. The articles that follow focus on the clinical, psychological, social, and attitudinal outcomes for patients, workers, families, and the public following the closing of CSH. [ABSTRACT FROM AUTHOR]

Substance abuse (SA) care has been excluded from recent federal and state legislation mandating equal benefits for mental health and medical care ("parity"), largely because of cost concerns. This article studies how many patients are affected by SA coverage limits and the likely implications of limits on insurance payments, using 1996-97 claims from 25 managed care plans with unlimited SA benefits. Changing even stringent limits on annual SA benefits has a small absolute effect on overall insurance costs under managed care, even though a large percentage of SA patients are affected. Removing an annual limit of $10,000 per year on SA care is estimated to increase insurance payments by about 6 cents per member per year, removing a limit of $1,000 increases payments by about $3.40. As long as care is comprehensively managed, "parity" for SA in employer-sponsored health plans is not very costly. [ABSTRACT FROM AUTHOR]

This study investigates how social workers, psychologists, and psychiatrists document the treatment they provide clients to managed behavioral health care organizations. The rosters of the Register of Clinical Social Workers, the American Psychological Association, and the American Psychiatric Association yielded a sample of 168 private practicing social workers, 158 psychologists, and 258 psychiatrists from across the nation. Results indicated that practitioners differed based on age, amount of time spent in private practice, racial self-identification, percentage of time with clients diminished due to communicating with managed behavioral health care organizations, and documentation of clients' prognoses. Some practitioners believe it is necessary to report treatment needs in ways to assure certification rather than in ways that accurately depict clients' clinical profiles. The ramifications for clinicians' evaluation of their own practices, reimbursement for their services, and meeting clients' needs while working under managed behavioral health care guidelines are discussed. [ABSTRACT FROM AUTHOR]

States differ widely in their delivery of pretrial forensic evaluation services, in terms of organizational structure and training requirements of forensic examiners. It was hypothesized that defendants adjudicated incompetent to proceed in states using community-based, private-practitioner systems would show less impairment on a competence assessment measure, the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA), than defendants adjudicated incompetent in states using traditional, inpatient systems. It also was hypothesized that mean MacCAT-CA scores for incompetent defendants from states requiring forensic training/certification would be lower than for defendants from states lacking such requirements. Results indicated significant differences across the four types of service delivery systems examined. However, planned comparisons revealed no differences between a state using a traditional, inpatient model and a state employing a community-based, private-practitioner model. Analyses examining the effects of mandatory forensic training failed to support the hypothesis that training requirements result in the adoption of higher thresholds for determining incompetence. [ABSTRACT FROM AUTHOR]

The cost and financing of mental health services is gaining increasing importance with the spread of managed care and cost-cutting measures throughout the health care system. The delivery of mental health services through structured employee assistance programs (EAPs) could be undermined by revised health insurance contracts and cutbacks in employer-provided benefits at the workplace. This study uses two recently completed national surveys of EAPs to estimate the costs of providing EAP services during 1993 and 1995. EAP costs are determined by program type, worksite size, industry, and region. In addition, information on program services is reported to determine the most common types and categories of services and whether service delivery changes have occurred between 1993 and 1995. The results of this study will be useful to EAP managers, mental health administrators, and mental health services researchers who are interested in the delivery and costs of EAP services. [ABSTRACT FROM AUTHOR]

An emerging trend within managed care, "disease management" (DM), will affect consumers and providers of mental health services, clinicians, and mental health administrators. Central to DM programs is the idea that particular diseases, especially chronic illnesses (including depression), can be "carved out" and managed. Pharmaceutical benefit management (PBM) firms may specialize in managing prescription benefits for employers and other managed care organizations by using DM programs. However, given what is known from the theoretical and empirical literature on adherence to medication for chronic illnesses such as depression, it is questionable whether the techniques that are used by PBMs will be effective in managing illnesses that require a multifaceted approach to care. Because the management of antidepressants may have an impact on members of vulnerable populations (e.g., the elderly), more research is required on the approaches used by PBMs and on the cost and quality of the services provided. [ABSTRACT FROM AUTHOR]

This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs. [ABSTRACT FROM AUTHOR]

The organization, financing, and delivery of publicly funded behavioral health services are undergoing massive changes nationwide. Managed care principles and practices are being implemented widely and are being relied on increasingly to meet the challenges of containing costs and improving service effectiveness. To meet these goals, comprehensive systems are under development for measuring and reporting outcomes experienced by individuals who received services and for assessing the impact of managed care strategies on the service delivery system. This article presents an example from the Prepaid Mental Health Program in New York State. It highlights the development, implementation, and early experiences with the plan's performance management system for public sector managed behavioral health, a basis for continuous quality improvement activities and information reporting products such as report cards. Policy, administrative, and financial implications are illuminated. [ABSTRACT FROM AUTHOR]

Increasing demands for accountability in the delivery of public mental health services are engendering organized systems of treatment outcome monitoring. As such systems are designed and implemented, it is critical that key stakeholders be involved to the greatest extent possible in developing assessment instruments and methodologies so as to ensure relevance and acceptability of the outcome management system. A multistakeholder-based initiative for developing standardized outcome assessment for public mental health services in Virginia is described. Key components of the initiative include the process by which stakeholders were enlisted, the identification of recommended assessment instruments, and a pilot project that began the evaluation of the feasibility, utility, and cost-benefit of using the instruments. To illustrate features of this initiative, the child/adolescent mental health pilot project is described in detail. Implications for behavioral health administrators and next steps for Virginia's outcome management system are discussed, highlighting the role of key stakeholders. [ABSTRACT FROM AUTHOR]