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Certified community behavioral health centers (CCBHCs) were established under section 223 of the Protecting Access to Medicare Act of 2014. CCBHCs had the goal of expanding access to care for people with behavioral health needs "regardless of ability to pay and place of residence." The authors used descriptive tables and a heat map to compare the geographic distribution of CCBHCs with county-level rates of mental illness, poverty, and population density. Regression models were employed to determine which county-level characteristics are most strongly associated with the establishment of a CCBHC. The authors found that population density is a stronger predictor of CCBHC presence than are rates of poverty or serious mental illness. Holding all other local characteristics constant, the authors observed that going from the population density typical of the most rural counties to that of the most urban counties was associated with an approximately 28-percentage-point increase (from 7% to 35%) in the likelihood of being served by a CCBHC. Expanding CCBHC services to areas with lower population densities likely requires an approach that is different from the current method of allocation of grant funds by the Substance Abuse and Mental Health Services Administration (SAMHSA). Two features of the program might be modified. The first would build on flexibilities incorporated into the most recent round of SAMHSA grantmaking, which explicitly aim to build infrastructure and capacity to develop a CCBHC. A second modification might seek to identify which certification requirements are essential to supporting CCBHC quality and access and eliminate nonessential requirements. [ABSTRACT FROM AUTHOR]

Lack of accountability contributes to the gap between best practices and potential outcomes. Few mental health providers routinely practice evidence-based care. In fact, within the mental health field, there is significant controversy over the use of evidence-based practices. Lack of accountability affects individuals receiving care at the patient level, provider level, and systems level. The authors identify several impediments to accountability in behavioral health care. These include failure to develop a diverse, well-trained workforce; challenges in measurement; misalignment of payment incentives; and misguided regulations. Accountability arrangements typically consist of several elements: a clear articulation of goals, objectives, or standards; metrics so that progress toward achieving goals can be tracked; and consequences for insurers, providers, and professionals for achieving or failing to achieve objectives. To advance system goals, the full complement of accountability tools should be consistently applied to all sources of behavioral health care and supports. The authors focus on three sets of accountability tools—performance metrics, payment incentives, and regulatory standards—that when implemented thoughtfully can help move the field toward more positive outcomes in behavioral health. [ABSTRACT FROM AUTHOR]

A major obstacle to mental health treatment for many Americans is accessibility: the United States faces a shortage of mental health providers, resulting in federally designated shortage areas. Although digital mental health treatments (DMHTs) are effective interventions for common mental disorders, they have not been widely adopted by the U.S. health care system. National and international expert stakeholders representing health care organizations, insurance companies and payers, employers, patients, researchers, policy makers, health economists, and DMHT companies and the investment community attended two Banbury Forum meetings. The Banbury Forum reviewed the evidence for DMHTs, identified the challenges to successful and sustainable implementation, investigated the factors that contributed to more successful implementation internationally, and developed the following recommendations: guided DMHTs should be offered to all patients experiencing common mental disorders, DMHT products and services should be reimbursable to support integration into the U.S. health care landscape, and an evidence standards framework should be developed to support decision makers in evaluating DMHTs. [ABSTRACT FROM AUTHOR]

Abstract Beyond the trends in the use of rehabilitative services in response to a new policy and its fiscal incentives, it is important to consider the effectiveness and quality of the services provided to individuals with mental disabilities in Israel. What is known about the outcomes of different rehabilitative services, and what is their value compared to other types of health and mental health services? Can typical health insurance be used to finance such services? These are some of the broader international questions raised by this report on the impact of a new law encouraging rehabilitation services in the community for individuals with psychiatric disabilities.

Mental illnesses provide a difficult set of challenges to American health and social institutions. Those challenges have been a continuous concern of David Mechanic's over the course of his career. In this article we trace the development of modern economic and organizational structures that drive the delivery of mental health care in the early part of the twenty-first century. We show how the nature of mental disorders themselves and the treatment for addressing those illnesses pose fundamental difficulties to health care organizational and financing structures. We analyze the factors that have caused the dramatic changes in how American society has addressed mental illnesses over the past fifty years. Specifically, we note the central influence that mainstream health, income support, and disability programs have had in shaping mental health care. We argue that the interaction of the unique features of mental illnesses and changes in mainstream health and social policy led mental health care to evolve so differently from general medical care. [ABSTRACT FROM AUTHOR]

The Patient Protection and Affordable Care Act (ACA) will expand coverage of mental health and substance use disorder benefits and federal parity protections to over 60 million Americans. The key to this expansion is the essential health benefit provision in the ACA that requires coverage of mental health and substance use disorder services at parity with general medical benefits. Other ACA provisions that should improve access to treatment include requirements on network adequacy, dependent coverage up to age 26, preventive services, and prohibitions on annual and lifetime limits and preexisting exclusions. The ACA offers states flexibility in expanding Medicaid (primarily to childless adults, not generally eligible previously) to cover supportive services needed by those with significant behavioral health conditions in addition to basic benefits at parity. Through these various new requirements, the ACA in conjunction with Mental Health Parity and Addiction Equity Act (MHPAEA) will expand coverage of behavioral health care by historic proportions. [ABSTRACT FROM AUTHOR]

Among the most prevalent chronic and disabling conditions for dually eligible beneficiaries are mental disorders-about 26 percent of dually eligible beneficiaries ages 65 years old or older have a mental disorder. Most older people with a mental disorder also suffer from anxiety disorder and less severe forms of depression, and mental disorders disrupt care of other chronic conditions like diabetes, congestive heart failure, and COPD. Spending in 2009 on older dual eligibles with a mental disorder was 2.5 times that of those without a mental disorder. Successful models of care coordination must manage mental health, substance-use-disorder services, medical care, and long-term services and supports. For older adults, the collaborative care model has shown promising results on cost and outcomes for addressing cases where anxiety and depression co-occur with chronic medical conditions like diabetes and COPD. [ABSTRACT FROM AUTHOR]

Objective: This study examined the impact of insurance parity on the use, cost, and quality of substance abuse treatment. Methods: The authors compared substance abuse treatment spending and utilization from 1999 to 2002 for continuously enrolled beneficiaries covered by Federal Employees Health Benefit (FEHB) plans, which require parity coverage of mental health and substance use disorders, with spending and utilization among beneficiaries in a matched set of health plans without parity coverage.Logistic regression models estimated the probability of any substance abuse service use. Conditional on use, linear models estimated total and out-of-pocket spending. Logistic regression models for three quality indicators for substance abuse treatment were also estimated: identification of adult enrollees with a new substance abuse diagnosis, treatment initiation, and treatment engagement. Difference-in-difference estimates were computed as (postparity -- preparity) differences in outcomes in plans without parity subtracted from those in FEHB plans. Results: There were no significant differences between FEHB and non-FEHB plans in rates of change in average utilization of substance abuse services. Conditional on service utilization, the rate of substance abuse treatment out-of-pocket spending declined significantly in the FEHB plans compared with the non-FEHB plans (mean difference=-$101.09, 95% confidence interval [CI]=-$198.06 to -$4.12), whereas changes in total plan spending per user did not differ significantly. With parity, more patients had new diagnoses of a substance use disorder (difference-in-difference risk=.10%, CI=.02% to .19%). No statistically significant differences were found for rates of initiation and engagement in substance abuse treatment. Conclusions: Findings suggest that for continuously enrolled populations, providing parity of substance abuse treatment coverage improved insurance protection but had little impact on utilization, costs for plans, or quality of care. [ABSTRACT FROM AUTHOR]

The private psychiatric hospital market has exhibited great volatility over time. From 1976 to 1992, the number of hospitals more than doubled, while in the decade following, the number of facilities dropped by half. Recently, however, the industry has begun to grow again. The evolution of this market reflects the response of a private industry with access to capital markets to changes in both the supply of substitutes and the demand for services. Most recently, the limited supply of facilities and expanded demand for psychiatric services have spurred renewed growth. The two leading firms today, Universal Health Services, Inc., which rode the market crest and downturn since the 1980s, and Psychiatric Solutions, Inc., a newer entrant, have employed different strategies to take advantage of these opportunities. The rapid responsiveness of the private psychiatric hospital market, as exemplified by these two firms, presents significant potential for shaping future mental health policy. [ABSTRACT FROM AUTHOR]

Mental health spending attracts attention from payers and policymakers. Historically, the public sector paid directly for a good deal of care, and special institutions and rules governed private-sector spending. During 1971-2002, spending on mental health care grew at much lower rates than spending on other health care. In recent years, the delivery and financing of mental health care have come to look more like those for general health care. We show that in spite of this convergence, important differences remain between general health and mental health care in patterns of spending growth. [ABSTRACT FROM AUTHOR]

Mental illness and its treatment are largely invisible. We use multiple publicly available data sources to evaluate changes in the well-being of Americans with mental illnesses over the past decade. We find that access to care, including specialty psychiatric and inpatient care, and financial protection have improved. However, not all people with mental health problems have shared in these improvements. Access to care among those with mental health impairments appears to have declined, and we estimate that because of continued increases in incarceration, at least 7 percent of the population with serious and persistent mental illnesses are incarcerated in jail or prison each year. [ABSTRACT FROM AUTHOR]

As the managed behavioral health care market has matured, behavioral health carve-outs have solved many problems facing the delivery of behavioral health services; at the same time, they have exacerbated existing difficulties or created new problems. Carve-outs developed to address rising inpatient behavioral health costs and limited insurance coverage. They are based on the economic principles of economies of specialization, economies of scale, price negotiation, and selection. Literature shows that carve-outs have been successful in lowering costs and maintaining or improving access, but results on their impact on quality of care are mixed. In recent years, carve-outs have evolved to take on new roles within the health system, such as coordinating mental and physical health, addressing fragmented public financing systems, and using market power to implement quality improvement. Although not perfect, carve-outs have been instrumental in addressing long-standing challenges in utilization, access, and cost of behavioral health care. [ABSTRACT FROM AUTHOR]

This Viewpoint discusses halting progress in legislative and policy attempts to make access to high-quality mental health and substance use disorders service equal to that for medical-surgical services and prospects for further regulation of insurance to achieve the goal. [ABSTRACT FROM AUTHOR]

The article evaluates the association between patterns of spending within a multifaceted, multilingual media campaign that advertised the availability of counseling services and the volume of calls received and referred to a counseling program in New York. It reports on the media campaign launched by the Office of Mental health after the September 11, 2001 terrorist attacks on the World Trade Center.

This article studies the differential effect of a managed behavioral health Carve-Out (CO) on outpatient treatment quality for persons with schizophrenia (SCHZ) alone and co-occurring substance use disorders (SUD). The COs are specialty health care organizations that are contracted by payers to separate part of their financial risk. This study uses a natural experiment in implementing a CO within a state Medicaid program to determine whether it had a differential impact on the quality of care for persons with only SCHZ or those with SUD.

Health accounts document changes over time in the level and composition of health spending. There has been a continued evolution in the ability to track such outlays. Less rapid has been the ability to interpret changes in spending. In this paper we apply quality adjusted price indexes for several major mental disorders to national mental health expenditure account estimates to assess changes in real "output". We show that using the new price indexes reveals large gains in real output relative to the application of the U.S. Bureau of Labor Statistics' indexes. [ABSTRACT FROM AUTHOR]

The article examines labor supply effects of interventions for major depressive disorder in the U.S. The results of randomized controlled trial suggest that interventions for patients with major depression can reduce depressive symptoms and increase labor output. Indications showed that the labor supply benefits are small relative to the improvement in clinical outcomes.

The article presents the authors' views on the development of cost-effective evidence-based models for treating depression in primary care. The authors say that economic and organizational barriers often impede sustainability in routine clinical practice. The Robert Wood Johnson Foundation funded eight demonstration grants to implement clinical changes in depression care in the Depression in Primary Care: Linking Clinical and System Strategies program. The article highlights certain elements that appear critical to realign incentives to support evidence-based depression care system.

Objectives. We compared differences in mental health needs and provision of mental health services among residents of Santiago, Chile, with private and public health insurance coverage. Methods. We conducted a cross-sectional survey of a random sample of adults. Presence of mental disorders and use of health care services were assessed via structured interviews. Individuals were classified as having public, private, or no health insurance coverage. Results. Among individuals with mental disorders, only 20% (95% confidence interval [CI]= 16%, 24%) had consulted a professional about these problems. A clear mismatch was found between need and provision of services. Participants with public insurance coverage exhibited the highest prevalence of mental disorders but the lowest rates of consultation; participants with private coverage exhibited exactly the opposite pattern. After adjustment for age, income, and severity; of symptoms, private insurance coverage (odds ratio [OR]= 2.72; 95% CI = 1.6, 4.6) and higher disability level (OR = 1.27, 95% CI = 1.1, 1.5) were the only factors associated with increased frequency of mental health consultation. Conclusions. The health reforms that have encouraged the growth of the private health sector in Chile also have increased risk segmentation within the health system, accentuating inequalities in health care provision. (Am J Public Health. 2006;96:109-113.) [ABSTRACT FROM AUTHOR]

Depression is a prevalent, often chronic condition that has enormous personal, social, and financial consequences. Although technologies for treating depression have advanced notably over the past 20 years, many people continue to suffer needlessly, due in part to the lack of evidence-based treatment applied in primary care settings. Substantial public and private efforts have been devoted to encouraging individuals to seek care, improving recognition and diagnosis by primary care physicians, and implementing evidence-based treatment practices. From these efforts have come new models of care as well as an awareness of the critical barriers impeding clinical, organizational, economic, and policy implementation of effective care strategies. In this paper, we describe these clinical and systems barriers and consider the perspectives of various stakeholder groups; present emerging clinical models for providing evidence-based care as well as economic strategies for overcoming barriers to their implementation; and propose community-based approaches that will need to be tested. To achieve maximum benefits from current knowledge, we will need to implement a multi-level strategy employing focused efforts involving patients, providers, practice settings, health plans, purchasers (public and private), and populations (or communities): the '6 P' strategy. [ABSTRACT FROM AUTHOR]

Focuses on the impact of Medicaid on mental health care in the U.S. Details on the increase in the Medicaid mental health policy; Effects of Medicaid on the economic rules of mental health care; Use of Medicaid in paying for long-term mental health care services.

Objective. To compare the performance of various risk adjustment models in behavioral health applications such as setting mental health and substance abuse (MH/SA) capitation payments or overall capitation payments for populations including MH/SA users. Data Sources/Study Design. The 1991-93 administrative data from the Michigan Medicaid program Were used. We compared mean absolute prediction error for several risk adjustment models and simulated the profits and losses that behavioral health care carve ours and integrated health plans would experience under risk adjustment if they enrolled beneficiaries with a history of MH/SA problems. Models included basic demographic adjustment Adjusted Diagnostic Groups, Hierarchical Condition Categories, and specifications designed for behavioral health. Principal findings. Differences in predictive ability among risk adjustment models were small and generally insignificant. Specifications based on relatively few MH/SA diagnostic categories did as well as or better than models controlling for additional variables such as medical diagnoses at predicting MH/SA expenditures among adults. Similarly analysis revealed that among both adults and minors considerable scope remained for behavioral health care carve outs to make profits or losses after risk adjustment based on differential enrollment of severely ill patients. Similarly, integrated health plans have strong financial incentives to avoid MH/SA users even after adjustment. Conclusions. Current risk adjustment methodologies do not eliminate the financial incentives for integrated health plans and behavioral health care carve-out plans to avoid high-utilizing patients with psychiatric disorders. [ABSTRACT FROM AUTHOR]

This article addresses issues related to the privatization of various functions within the mental health system. It acknowledges the contributions of Robert Dorwart, who explored trends with regard to the privatization of inpatient psychiatric services. The authors then highlight changes in the division of labor between the public and private sectors regarding the financing and delivery of mental health services and the management of the system. Responsibility for funding the mental health system has remained largely a public responsibility while responsibility for production or delivery of services in the mental health system is typically held by private, for-profit, and not-for-profit organizations. The roles of managing the mental health system and setting policy are now shared between the private and public sectors in a number of states that have implemented Medicaid behavioral health carve-out programs. This article explores the impact of such privatization on cost, access, and quality of services by examining the experiences of three states with carve-outs. The authors suggest that while organizational form is an important issue, concerns about privatization should be tempered by attention to the contracting decisions made by purchasers, the level of resources devoted to services, and the adequacy of administration of the system. [ABSTRACT FROM AUTHOR]

This study used 1994-1995 administrative data from a large public employer to examine the viability of commercial risk adjustment systems for setting capitation payments to competing behavioral health care "carve-outs". The ability of Hierarchical Condition Categories and Adjusted Diagnostic Groups to predict psychiatric expenditures was improved by controlling separately for psychiatric disability. However, even the best models underpredicted expenditures of patients with psychiatric disability by 15%. Relative to full capitation, "mixed" payment systems and soft capitation reduce the ability of carve-outs to earn disproportionate profits by enrolling healthy patients and avoiding sick ones, yet also diminish incentives for cost containment. [ABSTRACT FROM AUTHOR]

Proposes the systems cost-effectiveness (SCE) method for assessing the value of mental health care delivery system in the United States. Application of the SCE method to acute-phase treatment of depression; Approaches for defining value of mental health care; Factors considered in the assessing the value of mental health spending.

Discusses the political and economic forces in relation to mental health care parity laws. When the Domenici-Wellstone amendment was enacted; Provision of the amendment; Economic forces which affect coverage for mental illness and other conditions; Impact of parity laws in the era of managed care.

Examines the role of the public sector in the provision of mental health care in the United States. History of public policy toward the mentally ill since 1950s; Factors which contributed to the deinstitutionalization of long-term care; Growth in the role of the federal government in mental health care; Fragmentation of policy on mental health.

Discusses the implication of health insurance plans on the structured coverage for mental health and substance abuse. Restriction of employer-based health plans; Emergence of carv-out programs in public and private insurance plans charged with managing mental health costs; Representation in the continuation of historical discrimination.

This paper discusses various approaches to financing care for the severely mentally ill that make use of market-like incentives. It reviews the conditions under which each financing mechanism will work efficiently, discusses empirical evidence and practical considerations concerning service delivery to the severely mentally ill, and offers judgments about the specific situations where each mechanism might best be applied. [ABSTRACT FROM AUTHOR]

Objectives. This study compared the associations of individual mental health disorders, self-rated mental health, disability, and perceived need for care with the use of outpatient mental health services in the United States and the Canadian province of Ontario. Methods. Across-sectional study design was employed. Data came from the 1990 US National Comorbidity Survey and the 1990 Mental Health Supplement to the Ontario Health Survey. Results. The odds of receiving any medical or psychiatric specialty services were as follows: for persons with any affective disorder, 3.1 in the United States vs 11.0 in Ontario; for persons with fair or poor self-rated mental health, 2.7 in the United States VS 5.0 in Ontario; for persons with mental health-related disability, 3.0 in the United States vs 1.5 in Ontario. When perceived need was controlled for, most of the between-country differences in use disappeared. Conclusions. The higher use of mental health services in the United States than in Ontario is mostly explained by the combination of a higher prevalence of mental morbidity and a higher prevalence of perceived need for care among persons with low mental morbidity in the United States. [ABSTRACT FROM AUTHOR]

The author reflects on the Mental Health Treatment Study (MHTS) which examined the services for Social Security Disability Insurance (SSDI) beneficiaries with severe mental illness in the U.S. The study compared and evaluated two clinical care models for SSDI beneficiaries with severe mental illness. The implications of the study are discussed.

The author discusses the impact of mental health legislation in promoting equal insurance coverage for mental care. The author highlights the passing of the Mental Health Parity and Addiction Equity Act (MHPAEA) which seeks to provide comparability in the processes used by insurers to establish care management procedures.

The article presents the authors' views on the role of efficient outcome measurement in improving the quality of mental health care. It mentions that outcome measurement improves treatment response rate, reduces bad outcomes, and offers precise methods for tracking treatment progress and defining response. It adds that measuring the outcomes will assure that treatment procedures are effective in addressing the problems of mental health.

Background: To improve insurance coverage of mental health and substance-abuse services, the Federal Employees Health Benefits (FEHB) Program offered mental health and substance-abuse benefits on a par with general medical benefits beginning in January 2001. The plans were encouraged to manage care. Methods: We compared seven FEHB plans from 1999 through 2002 with a matched set of health plans that did not have benefits on a par with mental health and substance-abuse benefits (parity of mental health and substance-abuse benefits). Using a difference-in-differences analysis, we compared the claims patterns of matched pairs of FEHB and control plans by examining the rate of use, total spending, and out-of-pocket spending among users of mental health and substance-abuse services. Results: The difference-in-differences analysis indicated that the observed increase in the rate of use of mental health and substance-abuse services after the implementation of the parity policy was due almost entirely to a general trend in increased use that was observed in comparison health plans as well as FEHB plans. The implementation of parity was associated with a statistically significant increase in use in one plan (+0.78 percent, P<0.05) a significant decrease in use in one plan (−0.96 percent, P<0.05), and no significant difference in use in the other five plans (range, −0.38 percent to +0.23 percent; P>0.05 for each comparison). For beneficiaries who used mental health and substance-abuse services, spending attributable to the implementation of parity decreased significantly for three plans (range, −$201.99 to −$68.97; P<0.05 for each comparison) and did not change significantly for four plans (range, −$42.13 to +$27.11; P>0.05 for each comparison). The implementation of parity was associated with significant reductions in out-of-pocket spending in five of seven plans. Conclusions: When coupled with management of care, implementation of parity in insurance benefits for behavioral health care can improve insurance protection without increasing total costs. N Engl J Med 2006;354:1378-86. [ABSTRACT FROM AUTHOR]

Addresses the issue of whether parity between benefits for mental health care and those for other health care will result in equal access to mental health services and protect families against the financial consequences of mental disorders. Question of whether parity will result in better and more equitable mental health care. Reasons for the lack of parity between health care and mental health services; Approval of the Mental Health Equitable Treatment Act of 2001 by the United States Senate.

This paper examines recent trends in the design and organization of coverage for mental health care using data from a Henry J. Kaiser Family Foundation and Health Research and Educational Trust (KFF/HRET) national employer survey. Legislation and changes in the delivery of mental health services have altered how mental health insurance is bought and sold. However, our findings reveal that mental health coverage is still typically not offered at a level equivalent to coverage for other medical conditions. We attempt to synthesize these data with prior research as a foundation for informed debates. [ABSTRACT FROM AUTHOR]

Abstract: The study investigated the relationship of substance use disorders, concurrent psychiatric disorders, and patient demographics to patterns of treatment use and spending in behavioral health and medical treatment sectors. We examined claims data for individuals covered by the same organization. Services spending and use were examined for 1899 individuals who received substance use disorder treatment in 1997. Medical and pharmacy spending was assessed for 590 individuals (31.1%). The most prevalent services were outpatient, intensive outpatient, residential, and detoxification. Average mental health/substance abuse (MHSA) care spending conditional on use was highest for those with concurrent alcohol and drug disorders ($5235) compared to those with alcohol ($2507) or drugs ($3360) alone; other psychiatric illness ($4463) compared to those without ($1837); and employees’ dependents ($4138) compared to employees ($2875) or their spouses ($2744). A significant minority also sought MHSA services in the medical sector. Understanding services use and associated costs can best be achieved by examining services use across treatment sectors. [Copyright &y& Elsevier]