Cost shifting to jails after a change to managed mental health care

Medicaid Reimbursement For Psychiatric Services: Comparisons Across States And With Medicare

Medicaid is characterized by low rates of provider participation, often attributed to reimbursement rates below those of commercial insurance or Medicare. Understanding the extent to which Medicaid reimbursement for mental health services varies across states may help illuminate one lever for increasing Medicaid participation among psychiatrists. We used publicly available Medicaid fee-for-service schedules from state Medicaid agency websites in 2022 to construct two indices for a common set of mental health services provided by psychiatrists: a Medicaid-to-Medicare index to benchmark each state's Medicaid reimbursement with that of Medicare for the same set of services, and a state-to-national Medicaid index comparing each state's Medicaid reimbursement with an enrollment-weighted national average. On average, Medicaid paid psychiatrists at 81.0 percent of Medicare rates, and a majority of states had a Medicaid-to-Medicare index that was less than 1.0 (median, 0.76). State-to-national Medicaid indices for psychiatrists' mental health services ranged from 0.46 (Pennsylvania) to 2.34 (Nebraska) but did not correlate with the supply of Medicaid-participating psychiatrists. As policy makers look to reimbursement rates as one strategy to address ongoing mental health workforce shortages, comparing Medicaid payment across states may help benchmark ongoing state and federal proposals.

Medicaid Eligibility and Time to Re-incarceration Among Previously Incarcerated Subjects With Schizophrenia

Background: Many persons with severe mental illness qualify for Medicaid coverage. However, under federal law, states must either suspend or terminate eligibility once they are incarcerated. We hypothesize that prompt re-acquisition of Medicaid eligibility following release from incarceration lowers the risk of re-incarceration. Objective: To assess the relationship between Medicaid eligibility and risk of re-incarceration among previously incarcerated schizophrenia diagnosed subjects. Methods: Study subjects were selected between January 1, 2006 and September 30, 2011 from a single state Medicaid database that was combined with department of corrections data. Subjects were included if they had a schizophrenia diagnosis (International Classification of Diseases, 9th Revision, Clinical Modification [ICD- 9-CM] code 295.xx), were between the ages of 18 and 62, and had been released from incarceration. Covariates included age, race, gender, marital status, and reason for incarceration. Time to Medicaid eligibility after release from incarceration, cumulative days of eligibility, and whether they were eligible on the re-incarceration date were evaluated in independent models. One and three-year Cox Regression models analyses (p<0.05) were used to evaluate the hazard for re-incarceration. Results: The 932 subjects were 26.5% white, 73.7% male and were, on average, 37.6 years old on their index date (i.e., incarceration release date). They were 73.5% single or divorced and 12.7% were incarcerated for a substance abuse violation. In the 1-year follow-up period, 110 subjects (11.8%) were re-incarcerated. In the 3-year follow-up period 209 (22.4%) were re-incarcerated. Age (in years) was the only significant predictor of re-incarceration for the 1-year models (hazard ratio [HR]=0.976; confidence interval [CI]=0.957, 0.994). Eligibility was a significant predictor in the 3-year follow-up models. A longer 'time to first eligibility' (HR=1.046; CI=1.017, 1.075 was associated with a greater hazard for re-incarceration. Being eligible at the time of re-incarceration (HR=0.659; CI=0.498, 0.870) was associated with a lower hazard, and the cumulative number of months of eligibility (HR=0.978; CI=0.958, 0.997) and age were associated with a lower hazard for re-incarceration (HR=0.986; CI=0.973, 0.999). Conclusions: Access to Medicaid health services post-release may reduce the risk of re-incarceration.

Penrose's law: Methodological challenges and call for data

The investigation of the relationship between the sizes of the mental health population and the prison population, outlined in Penrose's Law, has received renewed interest in recent decades. The problems that arise in the course of the deinstitutionalization have repeatedly drawn attention to this issue. This article presents methodological challenges to the examination of Penrose's Law and retrospectively reviews historical data from empirical studies. A critical element of surveys is the sampling method; longitudinal studies seem appropriate here. The relationship between the numbers of psychiatric beds and the size of the prison population is inverse in most cases. However, a serious failure is that almost all of the data were collected in countries historically belonging to a Christian or Jewish cultural community. Only very limited conclusions can be drawn from these sparse and non-comprehensive data: a reduction in the number of psychiatric beds seems to be accompanied by increases in the numbers of involuntary admissions and forensic treatments and an accumulation of mentally ill persons in prisons. A kind of transinstitutionalization is currently ongoing. A pragmatic balance between academic epidemiological numbers and cultural narratives should be found in order to confirm or refute the validity of Penrose's Law. Unless comprehensive research is undertaken, it is impossible to draw any real conclusion.

Economics and the Transformation of the Mental Health System

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.

Economic Evaluation of Mental Health Interventions: A Guide to Costing Approaches

Costing approaches in the economic evaluation of mental health interventions are complicated by the broad societal impacts of mental health, and the multidisciplinary nature of mental health interventions. This paper aims to provide a practical guide to costing approaches across a wide range of care inputs and illness consequences relevant to the treatment of mental health. The resources needed to deliver mental health interventions are highly variable and depend on treatment settings (institutional, community), treatment providers (medical, non-medical) and formats (individual, group, electronic). Establishing the most appropriate perspective is crucial when assessing the costs associated with a particular mental health problem or when evaluating interventions to treat them. We identify five key cost categories (social care, informal care, production losses, crime and education) impacted by mental health and discuss contemporary issues in resource use measurement and valuation, including data sources and resource use instruments.

The heterogeneity of concentrated prescribing behavior: Theory and evidence from antipsychotics

We present two new findings based on annual antipsychotic US prescribing data from IMS Health on 2867 psychiatrists who wrote 50 or more prescriptions in 2007. First, many of these psychiatrists have prescription patterns that are statistically significantly different than random draws from national market shares for prescriptions by psychiatrists. For example, many have prescription patterns that are significantly more concentrated than such draws. Second, among psychiatrists who are the most concentrated, different prescribers often concentrate on distinct drugs. Motivated by these two findings, we then construct a model of physician learning-by-doing that fits these facts and generates two further predictions: both concentration (on one or a few drugs) and deviation (from the prescription patterns of others) should be smaller for high-volume physicians. We find empirical support for these predictions. Furthermore, our model outperforms an alternative theory concerning detailing by pharmaceutical representatives.

Economic impact of psychiatric relapse and recidivism among adults with schizophrenia recently released from incarceration: a Markov model analysis

OBJECTIVES

To develop an economic model that estimates the cost burden of psychiatric relapse and recidivism among patients with schizophrenia recently released from incarceration from a US state government perspective.

METHODS

A Markov state-transition model was developed to estimate the numbers of schizophrenia patients recently-released from incarceration who would experience psychiatric relapse and/or arrest and re-incarceration over a period of 3 years, along with corresponding costs. The model includes three health states: (1) in community, on therapy, (2) in community, off therapy, and (3) incarcerated. It is assumed that a patient's probability of psychiatric hospitalization increases with treatment discontinuation, and the probability of arrest increases with the occurrence of a prior psychiatric hospitalization. Data from the US Census and Bureau of Justice Statistics were used to estimate the model population. Published literature was used to estimate the risks of psychiatric relapse, arrest, and all cost inputs. State-specific incarceration rates and sentence length data (from the state of Florida) were applied. The impact on outcomes and costs was evaluated by varying the rates of anti-psychotic treatment following release from incarceration and the annual risk of medication discontinuation.

RESULTS

Among 34,500 persons released from incarceration in the state of Florida annually, 5307 were estimated to have schizophrenia. The cumulative 3-year costs to the state government were $21,146,000 and $25,616,000 for criminal justice and psychiatric hospitalization costs, respectively ($3984 per patient criminal justice; $4827 per patient hospitalization costs). A relative 20% increase in the proportion of patients receiving antipsychotic treatment following release from incarceration decreased total cumulative costs over 3 years by $1,871,100 ($353 per patient).

CONCLUSIONS

The economic impact of psychiatric relapse and recidivism among patients with schizophrenia is substantial from the state government perspective. This general model can be made state-specific by utilizing local criminal justice data sources.

Unintended consequences of cigarette price changes for alcohol drinking behaviors across age groups: evidence from pooled cross sections

BACKGROUND

Raising prices through taxation on tobacco and alcohol products is a common strategy to raise revenues and reduce consumption. However, taxation policies are product specific, focusing either on alcohol or tobacco products. Several studies document interactions between the price of cigarettes and general alcohol use and it is important to know whether increased cigarette prices are associated with varying alcohol drinking patterns among different population groups. To inform policymaking, this study investigates the association of state cigarette prices with smoking, and current, binge, and heavy drinking by age group.

METHODS

The 2001-2006 Behavioral Risk Factor Surveillance System surveys (n = 1,323,758) were pooled and analyzed using multiple regression equations to estimate changes in smoking and drinking pattern response to an increase in cigarette price, among adults aged 18 and older. For each outcome, a multiple linear probability model was estimated which incorporated terms interacting state cigarette price with age group. State and year fixed effects were included to control for potential unobserved state-level characteristics that might influence smoking and drinking.

RESULTS

Increases in state cigarette prices were associated with increases in current drinking among persons aged 65 and older, and binge and heavy drinking among persons aged 21-29. Reductions in smoking were found among persons aged 30-64, drinking among those aged 18-20, and binge drinking among those aged 65 and older.

CONCLUSIONS

Increases in state cigarette prices may increase or decrease smoking and harmful drinking behaviors differentially by age. Adults aged 21-29 and 65 and older are more prone to increased drinking as a result of increased cigarette prices. Researchers, practitioners, advocates, and policymakers should work together to understand and prepare for these unintended consequences of tobacco taxation policy.

Public health and the epidemic of incarceration

An unprecedented number of Americans have been incarcerated in the past generation. In addition, arrests are concentrated in low-income, predominantly nonwhite communities where people are more likely to be medically underserved. As a result, rates of physical and mental illnesses are far higher among prison and jail inmates than among the general public. We review the health profiles of the incarcerated; health care in correctional facilities; and incarceration's repercussions for public health in the communities to which inmates return upon release. The review concludes with recommendations that public health and medical practitioners capitalize on the public health opportunities provided by correctional settings to reach medically underserved communities, while simultaneously advocating for fundamental system change to reduce unnecessary incarceration.

Factors related to criminal justice expenditure trajectories for adults with serious mental illness

BACKGROUND

Criminal careers have been extensively studied in general population sample, but less is known about such patterns among people with major mental illness, and where so, criminal justice expenditure has not been taken into account.

AIMS

Our aim was to examine criminal justice system expenditure over time in one Florida county. Our main research question was whether treatment for mental disorders was related to a change in criminal offending and expenditure trajectory.

METHODS

We used the Pinellas County (Florida) Criminal Justice Information System to identify individuals under age 65 arrested between July 2003 and June 2004. Archival medical service, social and homeless services data were used to identify individuals with a serious mental illness. A two-step analysis was used to examine the data: first, we identified groups of people with similar patterns of criminal justice expenditures over 4 years (July 2002 to June 2006); second, we evaluated their demographic characteristics, diagnosis and treatment as potential predictors of group membership.

RESULTS

Three thousand seven hundred sixty-nine people with serious mental illness were identified in the Pinellas County jail population. Their average length of stay in jail was 151 days and in prison was 48 days. The trajectory analysis identified three groups of individuals with distinct trajectories of criminal justice expenditures: those with low stable, those with initially high but decreasing and those with initially high and sustained or increasing. Mental health treatment, whether acute or sustained, voluntary or mandatory, was associated with membership of the low stable group.

CONCLUSION

Review of criminal justice expenditure over time on individuals with major mental disorder may provide important indicators of unmet need for mental health services. Furthermore, it seems probable that improved provision of such services for them could reduce recidivism as well as improving health. Interventions may also be better focused if criminal justice expenditure trajectories are examined; programmes targeting re-offending as well as specific mental health problems may be most effective.

A comparison of policy and direct practice stakeholder perceptions of factors affecting evidence-based practice implementation using concept mapping

Background

The goal of this study was to assess potential differences between administrators/policymakers and those involved in direct practice regarding factors believed to be barriers or facilitating factors to evidence-based practice (EBP) implementation in a large public mental health service system in the United States.

Methods

Participants included mental health system county officials, agency directors, program managers, clinical staff, administrative staff, and consumers. As part of concept mapping procedures, brainstorming groups were conducted with each target group to identify specific factors believed to be barriers or facilitating factors to EBP implementation in a large public mental health system. Statements were sorted by similarity and rated by each participant in regard to their perceived importance and changeability. Multidimensional scaling, cluster analysis, descriptive statistics and t-tests were used to analyze the data.

Results

A total of 105 statements were distilled into 14 clusters using concept-mapping procedures. Perceptions of importance of factors affecting EBP implementation varied between the two groups, with those involved in direct practice assigning significantly higher ratings to the importance of Clinical Perceptions and the impact of EBP implementation on clinical practice. Consistent with previous studies, financial concerns (costs, funding) were rated among the most important and least likely to change by both groups.

Conclusions

EBP implementation is a complex process, and different stakeholders may hold different opinions regarding the relative importance of the impact of EBP implementation. Implementation efforts must include input from stakeholders at multiple levels to bring divergent and convergent perspectives to light.

Advancing a conceptual model of evidence-based practice implementation in public service sectors

Implementation science is a quickly growing discipline. Lessons learned from business and medical settings are being applied but it is unclear how well they translate to settings with different historical origins and customs (e.g., public mental health, social service, alcohol/drug sectors). The purpose of this paper is to propose a multi-level, four phase model of the implementation process (i.e., Exploration, Adoption/Preparation, Implementation, Sustainment), derived from extant literature, and apply it to public sector services. We highlight features of the model likely to be particularly important in each phase, while considering the outer and inner contexts (i.e., levels) of public sector service systems.

Increasing time costs and copayments for prescription drugs: an analysis of policy changes in a complex environment

OBJECTIVE

To estimate the effect of two separate policy changes in the North Carolina Medicaid program: (1) reduced prescription lengths from 100 to 34 days' supply, and (2) increased copayments for brand name medications.

DATA SOURCES/STUDY SETTING

Medicaid claims data were obtained from the Centers for Medicare and Medicaid Services for January 1, 2000-December 31, 2002.

STUDY DESIGN

We used a pre-post controlled partial difference-in-difference-in-differences design to examine the effect of the policy change on adults in North Carolina; adult Medicaid recipients from Georgia served as controls. Outcomes examined include medication adherence and Medicaid expenditures.

DATA COLLECTION/EXTRACTION METHODS

Data were aggregated to the person-quarter level. Individuals in HMOs, nursing homes, pregnant, or deceased in the quarter were excluded.

PRINCIPAL FINDINGS

Both policies decreased medication adherence. The days' supply policy had a much larger effect on adherence than did the copayment increase. Total Medicaid spending declined from the days' supply policy, but the copayment policy resulted in a net increase in Medicaid expenditures.

CONCLUSIONS

Although Medicaid costs decreased with the change in days supply policy, these savings were due to reduced adherence to these chronic medications. Additional research should examine the effect of these policy changes from the perspective of Medicaid enrollees.

Program planning and staff competencies for forensic assertive community treatment: ACT-eligible versus FACT-eligible consumers

PURPOSE

Forensic assertive community treatment (FACT) is a recent adaptation of the assertive community treatment (ACT) model; however, more information is needed about how FACT and ACT consumers differ and how FACT should be modified to accommodate these differences.

METHOD

Linked, multisystem administrative data from King County, Washington, were used to compare the demographic, clinical, and criminal justice characteristics of ACT- and FACT-eligible consumers.

RESULTS

FACT consumers were more likely to be male, persons of color, and had more complex clinical profiles. Also, some FACT consumers were incarcerated for sex offenses, and more than half had violent offenses.

CONCLUSIONS

Traditionally, ACT teams avoid serving consumers with personality disorders, violent consumers, and sex offenders; however, given increased use of mandated outpatient treatment and mental health courts, FACT teams may have less discretion to choose whom they serve. The addition of clinical interventions and other modifications may be particularly important for FACT teams.

Inpatient charges and mental illness: Findings from the Nationwide Inpatient Sample 1999-2007

Inpatient costs related to mental illness are substantial, though declining as a percentage of overall mental health treatment costs. The public sector has become increasingly involved in funding and providing mental health services. Nationwide Inpatient Sample data for the years 1999–2007 were used to: 1) examine Medicare, Medicaid, and private insurance charges related to mental illness hospitalizations, including trends over time; and 2) examine trends in mental comorbidity with physical illness and its effect on charges. There were an estimated 12.4 million mental illness discharges during the 9-year period, with Medicare being the primary payer for 4.3 million discharges, Medicaid for 3.3 million, private insurance for 3.2 million, and 1.6 million for all other payers. Mean inflation-adjusted charges per hospitalization were US$17,528, US$15,651, US$10,539, and US$11,663, respectively. Charges to public sources increased for schizophrenia and dementia-related discharges, with little private/public change noted for mood disorders. Comorbid mood disorders increased dramatically from 1.5 million discharges in 1999 to 3.4 million discharges in 2007. Comorbid illness was noted in 14.0% of the 342 million inpatient discharges during the study period and was associated with increased charges for some medical conditions and decreased charges for other medical conditions.

Implementing evidence-based practice in community mental health agencies: a multiple stakeholder analysis

OBJECTIVES

We sought to identify factors believed to facilitate or hinder evidence-based practice (EBP) implementation in public mental health service systems as a step in developing theory to be tested in future studies.

METHODS

Focusing across levels of an entire large public sector mental health service system for youths, we engaged participants from 6 stakeholder groups: county officials, agency directors, program managers, clinical staff, administrative staff, and consumers.

RESULTS

Participants generated 105 unique statements identifying implementation barriers and facilitators. Participants rated each statement on importance and changeability (i.e., the degree to which each barrier or facilitator is considered changeable). Data analyses distilled statements into 14 factors or dimensions. Descriptive analyses suggest that perceptions of importance and changeability varied across stakeholder groups.

CONCLUSIONS

Implementation of EBP is a complex process. Cross-system-level approaches are needed to bring divergent and convergent perspectives to light. Examples include agency and program directors facilitating EBP implementation by supporting staff, actively sharing information with policymakers and administrators about EBP effectiveness and fit with clients' needs and preferences, and helping clinicians to present and deliver EBPs and address consumer concerns.

[Penrose's law: reality or fiction? Mental health system and the size of prison population - international overview]

According to the Penrose's law, outlined on the basis of a comparative study of European statistics, there is an inverse relationship between the number of psychiatric beds and prison population. Based on international data, interrelationship among prison, asylum, psychiatric disease and criminal action are investigated in the present study, paying particular attention to the event of deinstitutionalization. Prevalence of mental and addictive diseases as well as psychological disturbances in prison is characterized by epidemiological data. As proposed by Penrose, an inverse relationship between the number of psychiatric beds and prison population can be observed in Hungary, too. To get a deeper insight into the mainstream of the events, economic, sociological, philosophical, as well as therapeutic aspects initializing deinstitutionalization are highlighted in the course of analysis. On the basis of data, it can be assumed that members the same population are confined to both systems. The author arrives at the conclusion that deinstitutionalization has in fact led to trans-institutionalization, because of, on one hand, the limited capacity of community treatment facilities; on the other hand, the community treatment itself cannot provide adequate treatment options to those suffering from severe, chronic mental diseases or comorbid states. In addition, the rate of financial support and the methods for prevention and treatment are insufficient to protect patients from the effects of revolving door.

Families and schizophrenia: the view from advocacy

Historically, families of persons who have schizophrenia often were blamed for the development of the condition and subsequently might have been excluded from care. Now these notions, which never had much systematic empiric support, have been abandoned. Family involvement often is critical to the recovery process and must be engaged actively whenever possible. This article calls for the inclusion of patients who have schizophrenia and their families in a redesigned model of care that is explicitly collaborative in its orientation and routinely includes evidence-based treatments that are informed by a vision of recovery.

Patient inducement, provider priorities, and resource allocation in public mental health systems

Public mental health systems are increasingly facing demands from the criminal justice system and social services agencies to provide services and support in cases in which mental illness contributes to crime, homelessness, or poverty. In this article we analyze how policies from outside public mental health systems affect resource allocation within these systems, using examples from criminal justice. These policies use two types of mechanisms: inducing patients to consume treatment (by offering rewards or imposing penalties) and inducing clinicians to provide treatment (by creating priorities). We propose a classification of these social policies based on whether they affect demand through rewards or penalties or supply through priorities. We then relate the classification to data on patients treated in public systems to evaluate the current prevalence and potential for growth in these outside demands. These inducements impose a set of nonobvious costs on other patients who are not targeted by the policies. Furthermore, they create incentives for both patients and providers to modify their behavior in order to take advantage of rewards, avoid penalties, or better compete for resources with prioritized patients. We consider some policy implications for avoiding unintended consequences of these policies.

Transitions between the public mental health system and jail for persons with severe mental illness: a Markov analysis

Proposed changes to the mental health care system are usually debated in terms of either health benefits or costs savings. However, because of the extensive intersection between the mental health system and the criminal justice system, changes in the organization and financing of mental health services may change the jail detention rate. We analyze jail incarcerations for felonies and non-felonies following the start of a public managed mental health care program in King County, Washington (including Seattle). We analyze unique data that tracks individuals in and out of the public mental health, Medicaid, and criminal justice systems for 1993-1998. In this manuscript we examine individuals with severe mental illness who were enrolled in the Washington state Medicaid program. The final sample size has monthly observations on 6766 unique individuals aged 18-64. We estimate Markov models of the monthly transition probabilities among living in the community with no public mental health treatment, receiving inpatient or outpatient mental health or substance abuse services, or being in jail for either a felony or non-felony charge. The transition probabilities are adjusted for demographics and policy changes that occurred during our study period. There is little evidence of any change in the jail detention rate for severely mentally ill users of the county mental health system in contrast with other SMI individuals following the public managed care program.

Perceived impact by administrators of psychiatric emergency services after changes in a state's mental health system

As a safety net, psychiatric emergency services are sensitive to system changes. To determine the impact of a state's changes in its mental health system, administrators of publicly funded psychiatric emergency services were surveyed. They reported few (M=0.8) negative changes in coordination of care but 77% endorsed change in administrative burden (54% saying it negatively affected quality of services). Reporting negative effect of administrative burden was associated with treating more persons with substance abuse problems and greater challenge posed by distance to local providers. These results suggest that impact of state-level changes was not uniform but associated with local characteristics.

Service costs for women with co-occurring disorders and trauma

Several aspects of costs related to health care and other service use at 6-month follow-up are presented for women with co-occurring mental health and substance abuse disorders with histories of physical and/or sexual abuse receiving comprehensive, integrated, trauma-informed and consumer/survivor/recovering person-involved interventions (n = 1023) or usual care (n = 983) in a nine-site quasi-experimental study. Results show that, controlling for pre-baseline use, there are no significant differences in total costs between participants in the intervention condition and those in the usual care comparison condition, either from a governmental (avg. US dollars 13,500) or Medicaid reimbursement perspectives (avg. just over US dollars 10,000). When combined with clinical outcomes analyzed in other works in this issue by Cocozza et al. (2005) and Morrissey et al. (2005), which favored the intervention sites, these cost findings indicate that the treatment intervention services are cost-effective as compared with the usual care received by women at the comparison sites.

Integrating care for patients with infectious, psychiatric, and substance use disorders: concepts and approaches

Patients with chronic viral infections such as HIV/AIDS or hepatitis C often have multiple co-existing problems such as psychiatric and addictive disorders, as well as social problems such as lack of housing, transportation and income that present challenging obstacles to successful management. Because services for these different problems are usually provided by different disciplines in varying locations, fragmentation of care can lead to treatment dropouts, lack of adherence, and poor outcomes. Integration strategies, ranging from simple efforts to improve communication and coordinate care to fully integrated multidisciplinary teams have been used to improve disease management. Although evidence for effectiveness is comprised primarily of observational studies of demonstration programmes, integration may be desirable on a pragmatic basis alone. Quality improvement strategies are attractive vehicles for implementing care integration and measuring its impact. Careful assessment of the problem to be solved and the development of targeted strategies will maximize chances of a successful outcome.