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This article uses a 4-pronged statistical approach to examine the impact of a mental health carve-out at a major employer. To examine net financial impact of the carve-out, the authors perform a pre-post, multivariate regression analysis of changes in costs. Using a random-effects model, the authors explore the ultimate financial impact of the carve-out for patients and for the firm. Using a multinomial logistic regression, they examine differing program effects by intensity of use. A fixed-effects negative binomial regression models the episodic nature of outpatient care, controlling for patient-specific unobserved characteristics that influence health care utilization. The carve-out slightly reduced overall mental health costs and utilization while expanding entry-level access to routine services. At the same time, the specific carve-out shifted financial burdens from the firm onto high-utilization patients. Therefore, this carve-out appears poorly suited to the care of individuals experiencing severe and debilitating psychiatric disorders. [ABSTRACT FROM AUTHOR]

As veterans age, chronic physical and psychiatric conditions increasingly challenge the Veterans Health Administration. We examine influences of age and diagnosis on health care utilization, within the context of the 1995 deinstitutionalization policy of the Veterans Health Administration. Veterans were hospitalized repeatedly over 5 years with diagnoses of schizophrenia, bipolar disorder, depression, or alcohol dependence (N = 7,719). Inpatient days decreased 14% from baseline while outpatient (OP) visits increased 63%, consistent with deinstitutionalization. In adjusted models, OP utilization greatly increased with age, but psychiatric visits-notably alcohol treatment--dropped sharply. Emergency visits rose after 1997, particularly for ethnic minorities. Individuals ages 35-49 and 50-64 years were the greatest consumers of OP care; these large, aging cohorts will continue to require additional services, taxing a burdened system. Utilization patterns evolve across the life course, requiring foresight to address changing demographic demands. Careful attention to mental health utilization patterns may help policy makers and providers understand psychiatric needs in older patients. [ABSTRACT FROM AUTHOR]

Objective: Peer support providers are part of the behavioral health workforce. Research indicates that peer support helps care recipients achieve recovery and engage with behavioral health services. This article investigated how many U.S. behavioral health facilities offer peer support services and compared the frequencies of peer support services in facilities providing mental health and substance use services., Methods: The authors conducted a secondary analysis of facilities in the Substance Abuse and Mental Health Services Administration's National Mental Health Services Survey (N=11,582) and the National Survey of Substance Abuse Treatment Services (N=13,585), including descriptive and comparative analyses on reported mental health and substance use treatment services in the 50 U.S. states in 2017., Results: The findings revealed state-to-state variation in the number and availability of mental health and substance use service facilities and in facilities that reported providing peer support services. Facilities providing substance use treatment services offered peer support services at more than twice the rate (56.6%) found in mental health facilities (24.7%). The authors also identified program characteristics associated with the inclusion of peer support services in behavioral health. Provision of peer support services was more frequently reported by public facilities than by for-profit and nonprofit facilities., Conclusions: Behavioral health facilities that serve individuals with serious mental illness and co-occurring substance use and mental health conditions reported offering peer support at a higher rate than did other facilities. Inconsistent definitions of peer support in the two surveys limited the comparability of the findings between the two reports., Competing Interests: The contents in this article are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. government.The authors report no financial relationships with commercial interests.

Suicide is the second leading cause of death among adolescents. As nearly 20% of adolescents visit emergency departments (EDs) each year, EDs have an opportunity to identify previously unrecognized suicide risk. A novel Computerized Adaptive Screen for Suicidal Youth (CASSY) was shown in a multisite study to be predictive for suicide attempts within 3 months. This study uses site-specific data to estimate the cost of CASSY implementation with adolescents in general EDs. When used universally with all adolescents who are present and able to participate in the screening, the average cost was USD 5.77 per adolescent. For adolescents presenting with non-behavioral complaints, the average cost was USD 2.60 per adolescent. Costs were driven primarily by time and personnel required for the further evaluation of suicide risk for those screening positive. Thus, universal screening using the CASSY, at very low costs relative to the cost of an ED visit, can facilitate services needed for at-risk adolescents.

Public health emergencies impact the well-being of people and communities. Long-term emotional distress is a pervasive and serious consequence of high levels of crisis exposure and low levels of access to mental health care. At highest risk for mental health trauma are historically medically underserved and socially marginalized populations and frontline health care workers (HCWs). Current public health emergency response efforts provide insufficient mental health services for these groups. The ongoing mental health crisis of the COVID-19 pandemic has implications for the resource-strained health care workforce. Public health has an important role in delivering psychosocial care and physical support in tandem with communities. Assessment of US and international public health strategies deployed during past public health emergencies can guide development of population-specific mental health care. The objectives of this topical review were (1) to examine scholarly and other literature on the mental health needs of HCWs and selected US and international policies to address them during the first 2 years of the pandemic and (2) to propose strategies for future responses. We reviewed 316 publications in 10 topic areas. Two-hundred fifty publications were excluded, leaving 66 for this topical review. Findings from our review indicate a need for flexible, tailored mental health outreach for HCWs after disasters. US and global research emphasizes the dearth of institutional mental health support for HCWs and of mental health providers who specialize in helping the health care workforce. Future public health disaster responses must address the mental health needs of HCWs to prevent lasting trauma.

The Affordable Care Act requires all insurance plans sold on health insurance marketplaces and individual and small-group plans to cover 10 Essential Health Benefits (EHB), including behavioral health services. Instead of applying a uniform EHB plan design, the Department of Health and Human Services let states define their own EHB plan. This approach was seen as the best balance between flexibility and comprehensiveness, and assumed there would be little state-to-state variation. Limited federal oversight runs the risk of variation in EHB coverage definitions and requirements, as well as potential divergence from standardized medical guidelines. We analyzed 112 EHB documents from all states for behavioral health coverage in effect from 2012 to 2017. We find wide variation among states in their EHB plan required-coverage, and divergence between medical-practice guidelines and EHB plans. These results emphasize consideration of federated regulation over health insurance coverage standards. Federal flexibility in states benefit design nods to state-specific policymaking-processes and population needs. However, flexibility becomes problematic if it leads to inadequate coverage that reduces access to critical health care services. The EHBs demonstrate an incomplete effort to establish appropriate minimum standards of coverage for behavioral health services.

Objective: Despite barriers, organizations with varying characteristics have achieved full integration of primary care services with providers and services that identify, treat, and manage those with mental health and substance use disorders. What are the key factors and common themes in stories of this success?, Methods: A systematic literature review and snowball sampling technique was used to identify organizations. Site visits and key informant interviews were conducted with 6 organizations that had over time integrated behavioral health and primary care services. Case studies of each organization were independently coded to identify traits common to multiple organizations., Results: Common characteristics include prioritized vulnerable populations, extensive community collaboration, team approaches that included the patient and family, diversified funding streams, and data-driven approaches and practices., Conclusions: While significant barriers to integrating behavioral health and primary care services exist, case studies of organizations that have successfully overcome these barriers share certain common factors., (© The Author(s) 2016.)

Objective: This study evaluated utilization of mental health and substance use services among enrollees at a large employee health plan following changes to benefit limits after passage in 2008 of federal mental health parity legislation., Methods: This study used a pre-post design. Benefits and claims data for 43,855 enrollees in the health plan in 2009 and 2010 were analyzed for utilization and costs after removal of a 30-visit cap on the number of covered mental health visits., Results: There was a large increase in the proportion of health plan enrollees with more than 30 outpatient visits after the cap's removal, an increase of 255% among subscribers and 176% among dependents (p<.001). The number of people near the 30-visit limit for substance use disorders was too few to observe an effect., Conclusions: Federal mental health parity legislation is likely to increase utilization of mental health services by individuals who had previously met their benefit limit.

Healthcare providers have increased the use of quality improvement (QI) techniques, but organizational variables that affect QI uptake and implementation warrant further exploration. This study investigates organizational characteristics associated with clinics that enroll and participate over time in QI. The Network for the Improvement of Addiction Treatment (NIATx) conducted a large cluster-randomized trial of outpatient addiction treatment clinics, called NIATx 200, which randomized clinics to one of four QI implementation strategies: (1) interest circle calls, (2) coaching, (3) learning sessions, and (4) the combination of all three components. Data on organizational culture and structure were collected before, after randomization, and during the 18-month intervention. Using univariate descriptive analyses and regression techniques, the study identified two significant differences between clinics that enrolled in the QI study (n = 201) versus those that did not (n = 447). Larger programs were more likely to enroll and clinics serving more African Americans were less likely to enroll. Once enrolled, higher rates of QI participation were associated with clinics' not having a hospital affiliation, being privately owned, and having staff who perceived management support for QI. The study discusses lessons for the field and future research needs.

Objectives: To assess the financial effect of the 2008 Hospital-Acquired Conditions Initiative (HACI) pressure ulcer payment changes on Medicare, other payers, and hospitals., Design: Retrospective before-and-after study of all-payer statewide administrative data for more than 2.4 million annual adult discharges in 2007 and 2009 using the Healthcare Cost and Utilization Project State Inpatient Datasets for California. How often and by how much the 2008 payment changes for pressure ulcers affected hospital payment was assessed., Setting: Nonfederal acute care California hospitals (N = 311)., Participants: Adults discharged from acute-care hospitals., Measurements: Pressure ulcer rates and hospital payment changes., Results: Hospital-acquired pressure ulcer rates were low in 2007 (0.28%) and 2009 (0.27%); present-on-admission pressure ulcer rates increased from 2.3% in 2007 to 3.0% in 2009. According to clinical stage of pressure ulcer (available in 2009), hospital-acquired Stage III and IV ulcers occurred in 603 discharges (0.02%); 60,244 discharges (2.42%) contained other pressure ulcer diagnoses. Payment removal for Stage III and IV hospital-acquired ulcers reduced payment in 75 (0.003%) discharges, for a statewide payment decrease of $310,444 (0.001%) for all payers and $199,238 (0.001%) for Medicare. For all other pressure ulcers, the Hospital-Acquired Conditions Initiative reduced hospital payment in 20,246 (0.81%) cases (including 18,953 cases with present-on-admission ulcers), reducing statewide payment by $62,538,586 (0.21%) for all payers and $47,237,984 (0.32%) for Medicare., Conclusion: The total financial effect of the 2008 payment changes for pressure ulcers was negligible. Most payment decreases occurred by removal of comorbidity payments for present-on-admission pressure ulcers other than Stages III and IV. The removal of payment for hospital-acquired Stage III and IV ulcers by implementation of the HACI policy was 1/200th that of the removal of payment for other types of pressure ulcers that occurred in implementation of the Hospital-Acquired Conditions Initiative., Competing Interests: All authors have completed and submitted the ICJME Form for Disclosure of Potential Conflicts of Interest. The remaining authors report no conflicts of interest., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Objective: Despite the prevailing consensus as to its value, the adoption of integrated care models is not widespread. Thus, the objective of this article it to examine the barriers to the adoption of depression and primary care models in the United States., Methods: A literature search focused on peer-reviewed journal literature in Medline and PsycInfo. The search strategy focused on barriers to integrated mental health care services in primary care, and was based on previously existing searches. The search included: MeSH terms combined with targeted keywords; iterative citation searches in Scopus; searches for grey literature (literature not traditionally indexed by commercial publishers) in Google and organization websites, examination of reference lists, and discussions with researchers., Findings: Integration of depression care and primary care faces multiple barriers. Patients and families face numerous barriers, linked inextricably to create challenges not easily remedied by any one party, including the following: vulnerable populations with special needs, patient and family factors, medical and mental health comorbidities, provider supply and culture, financing and costs, and organizational issues., Conclusions: An analysis of barriers impeding integration of depression and primary care presents information for future implementation of services.

Assessing the value of clinical and translational research funding on accelerating the translation of scientific knowledge is a fundamental issue faced by the National Institutes of Health (NIH) and its Clinical and Translational Awards (CTSAs). To address this issue, the authors propose a model for measuring the return on investment (ROI) of one key CTSA program, the clinical research unit (CRU). By estimating the economic and social inputs and outputs of this program, this model produces multiple levels of ROI: investigator, program, and institutional estimates. A methodology, or evaluation protocol, is proposed to assess the value of this CTSA function, with specific objectives, methods, descriptions of the data to be collected, and how data are to be filtered, analyzed, and evaluated. This article provides an approach CTSAs could use to assess the economic and social returns on NIH and institutional investments in these critical activities.

Objective: Hospitalization is a critical component of treatment for individuals with serious and persistent mental illness. Despite its resource intensity, the costs of inpatient psychiatric hospitalizations in the United States are not well understood. The objective of this research was to provide cost estimates for inpatient psychiatric care., Methods: Using Premier's Perspective Comparative Database, supplemented with the MarketScan database, this study estimated the average charges, cost to provide care, and amount of reimbursement for inpatient psychiatric care in 418 community-based hospitals in 2006 (N=261,996 hospitalizations)., Results: Charges were 2.5 times higher than the hospitals' reported costs to deliver care. Reimbursed amounts indicated by MarketScan were similar to the reported costs to deliver care. The average cost to deliver care was highest for Medicare and lowest for the uninsured: schizophrenia treatment, $8,509 for 11.1 days and $5,707 for 7.4 days, respectively; bipolar disorder treatment, $7,593 for 9.4 days and $4,356 for 5.5 days; depression treatment, $6,990 for 8.4 days and $3,616 for 4.4 days; drug use disorder treatment, $4,591 for 5.2 days and $3,422 for 3.7 days; and alcohol use disorder treatment, $5,908 for 6.2 days and $4,147 for 3.8 days., Conclusions: Consistent with past research, the results suggest that previous attempts to control pricing may have led to unintended consequences, including a large gap between charges and reimbursed amounts, potential cost shifting between payers, and potentially extended lengths of stay to offset reduced per diems. The lack of transparency in pricing makes it challenging to estimate the cost to society for a day of psychiatric hospitalization.

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance? To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the law's enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.

Objective: To investigate the course of alcoholism in males and females in a 14-year follow-up of persons with DSM-III alcoholism compared to very heavy drinkers and unaffected controls in a community sample., Methods: Case-control study based on data from the 1997 Health Services Use and Cost study, a 14-year follow-up survey of 442 individuals who participated in two waves of the 1981-1983 St. Louis Epidemiologic Catchment Area study. Cases met criteria for DSM-III alcohol abuse (AA) or dependence (AD) at both waves of the ECA: "Two-times Alcohol Use Disorder Positives (ECA 2t-AUDPs)." Two comparison groups were frequency matched to 2t-AUDPs: (1) ECA Very Heavy Drinkers/One-time Alcohol Use Disorder Positives (ECA VHD/1t-AUDPs) and (2) ECA alcohol-unaffecteds. Lifetime and past year alcohol use disorders, patterns of drinking and recovery among males and females are reported., Results: 84.6% of 2t-AUDPs again met lifetime DSM-III criteria at 14-year follow-up. At follow-up, only 9.3% male 2t-AUDPs and 20.7% female 2t-AUDPs met past year DSM-IV AUD criteria. Past year drinking patterns, however, revealed higher rates of DSM-IV AA or AD, problem or risk drinking among 2t-AUDPs (61.7%) compared to both ECA VHD/1t-AUDPs (41.2%) and ECA alcohol-unaffecteds (22.1%)., Conclusions: In a community sample, the rate of past year DSM-IV alcohol dependence was lower among male 2t-AUDPs than females, though both groups showed past year rates substantially lower than lifetime rates. However, less than half of ECA 2t-AUDPs exhibited low-risk or abstinent alcohol use behaviors, indicating that while remission from diagnosis is common, clinical relevance persists.

Objective: To assess the effect of the 2002 Veterans Millennium Health Care Act, which raised pharmacy copayments from $2 to $7 for lower-priority patients, on medication refill decisions and health services utilization among vulnerable veterans with schizophrenia., Study Design: Quasi-experimental., Methods: This study used secondary data contained in the National Psychosis Registry from June 1, 2000, through September 30, 2003, for all veterans diagnosed with schizophrenia and receiving healthcare through the Department of Veterans Affairs (VA). Longitudinal, mixed models were used to observe changes in prescriptions, health services utilization, and pharmacy costs in veterans subject to copayments (N = 40 654) and a control group of exempt individuals (N = 39 983). Analyses controlled for demographics, substance abuse, non-VA utilization, and medical comorbidities. The Health Belief Model supported analytical criteria for factors directly related to medication adherence issues., Results: Total prescriptions and overall pharmacy costs leveled among veterans with copayments after the medication cost increase. However, psychiatric drug refills dropped substantially, nearly 25%. Although outpatient visits were unaffected, psychiatric admissions and total inpatient days increased slightly, particularly 10 to 20 months after the policy change. Factoring in additional copayment revenue, the VA realized a $14.7-million annual net revenue gain from this subpopulation alone., Conclusion: These results suggest the new policy successfully reduced utilization and costs, with perhaps minimal clinical consequences to date. However, higher inpatient utilization resulting from cost-related nonadherence is troubling within an already high-risk and poorly adherent population, especially considering the reduction in psychiatric drug refills.

While early growth in preferred provider organizations (PPOs) coincided with growth of managed care generally, recent expansion has come primarily at the expense of other managed care plans. Little is known about the micro behavior underlying these trends. In 2005, University of Michigan employees were offered PPOs for the first time by vendors who also offered other plans. PPOs helped the offering vendors maintain or increase their total enrollment share. PPOs were most attractive to workers who previously had chosen less managed plans. Because PPOs drew few enrollees from health maintenance organizations (HMOs), there was little evidence of a backlash against managed care in the context of the University of Michigan employee group.

Entrepreneurship is often described as the ability to create new ventures from new or existing concepts, ideas and visions. There has been significant entrepreneurial response to the changes in the scientific and social underpinnings of health care services delivery. However, a growing portion of the economic development driving health care industry expansion is threatened further by longstanding use of financing models that are suboptimal for health care ventures. The delayed pace of entrepreneurial activity in this industry is in part a response to the general economy and markets, but also due to the lack of capital for new health care ventures. The recent dearth of entrepreneurial activities in the health services sector may also due to failure to consider new approaches to partnerships and strategic ventures, despite their mutually beneficial organizational and financing potential. As capital becomes more scarce for innovators, it is imperative that those with new and creative ideas for health and health care improvement consider techniques for capital acquisition that have been successful in other industries and at similar stages of development. The capital and added expertise can allow entrepreneurs to leverage resources, dampen business fluctuations, and strengthen long term prospects.

A goal of the Robert Wood Johnson Depression and Primary Care Initiative at the University of Michigan is to create and implement the clinical care and financial systems necessary to enable links between primary care and mental health specialty depression care. This paper describes the economic issues related to resources required, the mechanisms to distribute those resources, and the support that must be garnered from stakeholders. By systematic measurement and application, we assess the cost, price and selected consequences of these efforts. The study illustrates the need for both centralized and distributed capacity and support for innovative models of care.

This paper briefly reviews the recent history of psychosocial treatment for adults with severe mental illnesses in the United States. It examines the current sources and financing of such care, revealing the planned and unplanned reclassification of entitled beneficiaries and eligible patients, appropriate treatment, acceptable outcomes, and levels and sources of payment. One illustration of this phenomenon is seen in current efforts to identify and deliver only those public services that are covered by Medicaid, so as to allocate state resources only when they can be matched by federal monies. Another is the reliance on private health insurance, tied in the U.S. almost exclusively to employment, for medical care delivered under an acute, rather than a chronic care model. These analyses conclude with a discussion of the implicit and explicit mechanisms used to ration access to psychosocial treatment in the United States. The implications for individuals with serious mental illnesses, their families, and the general public are placed in historical and current policy contexts, recognizing the economic, social, and clinical variables that can moderate outcomes.

Objective: To investigate whether different risk-adjustment methodologies and economic profiling or "practice efficiency" metrics produce differences in practice efficiency rankings for a set of primary care physicians (PCPs)., Data Source: Twelve months of claims records (inpatient, outpatient, professional, and pharmacy) for an independent practice association HMO., Study Design: Patient risk scores obtained with six profiling risk-adjustment methodologies were used in conjunction with claims cost tabulations to measure practice efficiency of all primary care physicians who managed 25 or more members of an HMO., Data Collection: For each of the risk-adjustment methodologies, two measures of "efficiency" were constructed: the standardized cost difference between total observed (standardized actual) and total expected costs for patients managed by each PCP, and the ratio of the PCP's total observed to total expected costs (O/E ratio). Primary care physicians were ranked from most to least efficient according to each risk-adjusted measure, and level of agreement among measures was tested using weighted kappa. Separate rankings were constructed for pediatricians and for other primary care physicians., Findings: Moderate to high levels of agreement were observed among the six risk-adjusted measures of practice efficiency. Agreement was greater among pediatrician rankings than among adult primary care physician rankings, and, with the standardized difference measure, greater for identifying the least efficient than the most efficient physicians. The O/E ratio was shown to be a biased measure of physician practice efficiency, disproportionately targeting smaller sized panels as outliers., Conclusions: Although we observed moderate consistency among different risk-adjusted PCP rankings, consistency of measures does not prove that practice efficiency rankings are valid, and health plans should be careful in how they use practice efficiency information. Indicators of practice efficiency should be based on the standardized cost difference, which controls for number of patients in a panel, instead of O/E ratio, which does not.

This paper examines the relative accuracy of risk-adjustment methodologies used to profile primary care physician practice efficiency. Claims and membership data from an independent practice association health maintenance organization (HMO) were processed through risk-adjustment software of six different profiling methodologies. The Group R2 statistic was used to measure, for simulated panels of HMO members, how closely each methodology's cost predictions matched the panel's actual costs. All but one methodology explained at least 50% of panel cost variance with panels as small as 25 patients. Group R2 performance tended to be better when high-cost cases were included rather than excluded from the analyses.

This article documents a unique organizational, legal, and financial partnership between a state, a university, a Medicaid managed health care plan, and a county to provide integrated mental health, substance abuse, and primary and specialty health care services to Medicaid, low-income, and indigent consumers in Washtenaw county, Michigan. Major regulatory, financial, and clinical changes were required within and among the various partners in the Washtenaw County Integrated Health Care Project. A new entity--the Washtenaw Community Health Organization--was created to implement the project. By sharing resources as well as financial risks, the state, the county, and the university have been able to provide ongoing integrated care to a vulnerable population of patients. Although resource intensive in conceptualization and implementation, the project can be viewed as a model for other states that face growing needy populations and decreasing Medicaid budgets.

Managed behavioral health care is increasingly being used in public mental health systems. While supporters cite potential benefits, critics describe dire consequences for individuals with serious, long-term mental illness. The situation has parallels with the major changes resulting from deinstitutionalization some four decades ago. Believing that analyzing history may prevent repeating some of its mistakes, the authors compare the antecedents, benefits, and negative effects of deinstitutionalization with those of the public-sector managed behavioral health care systems being developed today. Lessons learned from the earlier era include the need for careful general and technical planning; for assignment of responsibility, including monitoring, to the public sector; and for a focus on clients and the special needs generated by severe mental illnesses.

The purpose of this study is to determine the extent to which health maintenance organization (HMO) penetration within the public hospitals' market area affects the financial performance and viability of these institutions, relative to private hospitals. Hospital- and market-specific measures are examined in a fully interacted model of over 2,300 hospitals in 321 metropolitan statistical areas (MSAs) in 1995. Although hospitals located in markets with higher HMO penetration have lower financial performance as reflected in revenues, expenses and operating margin, public hospitals are not more disadvantaged than other hospitals by managed care.

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.

To control the rise in expenditures and to increase access to mental health and substance abuse (MH/SA) services, a growing number of employers and states are implementing a "carve-out." Under this arrangement, the sponsor separates insurance benefits by disease or condition, service category, or population and contracts separately for the management of care and/or associated risks. A carve-out allows a unique set of managed care techniques to be applied to a subset of particularly costly or complex benefits. This article describes various carve-out models, discusses the potential advantages and disadvantages of a full carve-out, and summarizes recent public and private sector research regarding the strategy's effects on access and use, cost savings and shifting, and quality of care. It concludes by discussing approaches to the assessment and monitoring of the processes and outcomes associated with a MH/SA carve-out.

This paper describes a cross-sectional study of institutions for mental diseases (IMDs) and the clients they serve in one state. Primary and secondary data were collected to provide an in-depth look at the demographic, social, behavioral, medical, psychiatric and treatment attributes of a random sample of clients in IMDs. Detailed financial, service and operational data were collected on a 100% sample of facilities in the state. The findings indicated a client population dissimilar in age and behavioral attributes from a typical nursing home patient, but in keeping in many respects with the descriptions of nursing home clients with psychiatric disorders. Facilities appeared similar to nursing homes in their size and many operations. This unique database can be used to explore a predictive resource model of these institutions as well as to begin to examine the quality and effectiveness of this form of institutional care for the severely mentally ill.