Reimbursement for a Broader Array of Services in Coordinated Specialty Care for Early Psychosis

Despite the growing evidence supporting the benefits of coordinated specialty care (CSC) for early psychosis, access to this multimodal, evidence-based program in the United States has been hindered by a lack of funding for core CSC services and activities. The recent approval of team-based reimbursement codes by the Centers for Medicare and Medicaid Services has the potential to fund substantially more CSC services for clients with insurance coverage that accepts the new team-based billing codes. This streamlined and more inclusive billing strategy may reduce administrative burden and support the financial viability of CSC programs.

Financing Early Psychosis Intervention Programs: Provider Organization Perspectives

OBJECTIVE

The authors aimed to identify prominent financing approaches for coordinated specialty care (CSC) of patients with first-episode psychosis, alignment or misalignment of such approaches with sustained CSC implementation, and CSC provider perspectives on ideal payment models.

METHODS

Semistructured interviews were conducted with informants from CSC provider organizations. Purposeful sampling of CSC program directors, team leaders, and other administrators from a national e-mail Listserv was supplemented by snowball sampling via participant recommendations. Interview data from 19 CSC programs in 14 states were analyzed by using an integrated (inductive and deductive) approach to derive themes.

RESULTS

The results indicated that financing approaches to CSC were patchwork and highly varied. Three major sources of funding were cited: insurance billing (largely fee for service [FFS] to Medicaid and private insurance), set-aside funding from the federal Mental Health Block Grant (MHBG) program, and state funding. The findings revealed limited coverage and restrictive rules associated with FFS insurance billing that were misaligned with CSC implementation. The grant nature of MHBG and other public funding was seen as a threat to long-term CSC sustainability and deployment. CSC stakeholders endorsed a bundled-payment approach by public and private payers and supported tying payment to client outcomes to reflect CSC's recovery orientation.

CONCLUSIONS

Reliance on FFS insurance billing and public funding is likely to be unsustainable. Additionally, FFS billing is misaligned with CSC goals. Because of the diversity in CSC programs, populations, and existing funding mechanisms and rules, payer-provider collaboration will be essential in designing a bundled-payment model that meets local needs.

Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives

OBJECTIVE

In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study.

METHODS

Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses.

RESULTS

Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge.

CONCLUSIONS

CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Continue, adjust, or stop antipsychotic medication: developing and user testing an encounter decision aid for people with first-episode and long-term psychosis

BACKGROUND

People with psychosis struggle with decisions about their use of antipsychotics. They often want to reduce the dose or stop, while facing uncertainty regarding the effects these decisions will have on their treatment and recovery. They may also fear raising this issue with clinicians. The purpose of this study was to develop and test a shared decision making (SDM) tool to support patients and clinicians in making decisions about antipsychotics.

METHODS

A diverse editorial research team developed an Encounter Decision Aid (EDA) for patients and clinicians to use as part of the psychiatric consultation. The EDA was tested using 24 semistructured interviews with participants representing six stakeholder groups: patients with first-episode psychosis, patients with long-term psychosis, family members, psychiatrists, mental health counselors, and administrators. We used inductive and deductive coding of interview transcripts to identify points to revise within three domains: general impression and purpose of the EDA; suggested changes to the content, wording, and appearance; and usability and potential contribution to the psychiatric consultation.

RESULTS

An EDA was developed in an iterative process that yielded evidence-based answers to five frequently asked questions about antipsychotic medications. Patients with long-term psychosis and mental health counselors suggested more changes and revisions than patients with first-episode psychosis and psychiatrists. Family members suggested more revisions to the answers about potential risks of stopping or adjusting antipsychotics than other respondents.

CONCLUSIONS

The EDA was perceived as potentially useful and feasible in psychiatric routine care, especially if presented during the consultation.

Advancing Science Through Collaborative Data Sharing and Synthesis

The demand for researchers to share their data has increased dramatically in recent years. There is a need to replicate and confirm scientific findings to bolster confidence in many research areas. Data sharing also serves the critical function of allowing synthesis of findings across trials. As innovative statistical methods have helped resolve barriers to synthesis analyses, data sharing and synthesis can help answer research questions that cannot be answered by individual trials alone. However, the sharing of data among researchers remains challenging and infrequent. This article aims to (a) increase support for data sharing and synthesis collaborations among researchers to advance scientific knowledge and (b) provide a model for establishing these collaborations using the example of the ongoing National Institute of Mental Health's Collaborative Data Synthesis on Adolescent Depression Trials. This study brings together datasets from existing prevention and treatment trials in adolescent depression, as well as researchers and stakeholders, to answer questions about "for whom interventions work" and "by what pathways interventions have their effects." This is critical to improving interventions, including increasing knowledge about intervention efficacy among minority populations, or what we call "scientific equity." The collaborative model described is relevant to fields with research questions that can only be addressed by synthesizing individual-level data.

After Newtown: mental illness and violence

In the wake of the latest mass shooting, there are calls to marshal the evidence and take steps to identify and treat mental illness early in life.

Cost-sharing requirements and access to mental health care among medicare enrollees with schizophrenia

OBJECTIVE

This study explored the association between Medicare cost-sharing requirements and the probability of use of various mental health outpatient services among Medicare enrollees with schizophrenia.

METHODS

Multivariate logistic regression was used to estimate the probability of use of each of seven types of services over six months. Patients were recruited from public and private mental health treatment provider organizations in six states. The analyses included 1,088 Medicare enrollees, of whom approximately 55 percent were also enrolled in Medicaid.

RESULTS

Medicare-only patients (with greater cost-sharing) were 25 to 45 percent less likely to have used rehabilitation services, individual therapy with nonpsychiatrist mental health providers, and case management. No association was found between Medicaid enrollment and probability of service use for medical clinic visits, group therapy, individual contact with a psychiatrist, or receipt of second-generation antipsychotics.

CONCLUSIONS

Among Medicare enrollees with schizophrenia, gaps in Medicare coverage may be more problematic for rehabilitation, case management, and contact with nonpsychiatrist providers. Local public and private subsidies for mental health treatment may compensate for some of the gaps in coverage. However, such subsidies are not universally or uniformly provided.

Preferences for schizophrenia treatment outcomes among public policy makers, consumers, families, and providers

OBJECTIVE

This study measured state public policy makers' ratings of the importance of several key schizophrenia treatment outcomes and compared them with the ratings of primary stakeholders in schizophrenia treatment.

METHODS

Three groups of policy makers (40 administrative decision makers, 40 state legislators, and 20 legislative aides) and three groups of core stakeholders (20 persons with schizophrenia, 13 of their family members, and 20 of their mental health care providers) were recruited in Florida. Participants rated 12 descriptions of schizophrenia-related health states that reflected better and worse outcomes in six domains: psychotic symptoms, deficit symptoms, medication side effects, productive activity, daily activity, and social activity.

RESULTS

All participants valued functional outcomes, such as improved productive and social activity, more than they valued improvements in symptoms. Public policy makers and primary stakeholders differed in the value they placed on two of the six outcomes. Compared with primary stakeholders, policy makers valued improvements in social functioning significantly more and improvements in medication side effects significantly less.

CONCLUSIONS

Policy makers and primary stakeholders place similar value on some of the major goals of schizophrenia treatment, with both groups valuing functional outcomes most highly. However, the difference between groups in the importance placed on medication side effects may lead to conflicts in the allocation of resources to the provision of newer and more expensive medications, which are associated with fewer side effects. This initial examination of policy makers' views provides a starting point for developing consensus about schizophrenia treatment policies.

Managed behavioral health care: an instrument to characterize critical elements of public sector programs

OBJECTIVE

To develop an instrument to characterize public sector managed behavioral health care arrangements to capture key differences between managed and "unmanaged" care and among managed care arrangements.

STUDY DESIGN

The instrument was developed by a multi-institutional group of collaborators with participation of an expert panel. Included are six domains predicted to have an impact on access, service utilization, costs, and quality. The domains are: characteristics of the managed care plan, enrolled population, benefit design, payment and risk arrangements, composition of provider networks, and accountability. Data are collected at three levels: managed care organization, subcontractor, and network of service providers.

DATA COLLECTION METHODS

Data are collected through contract abstraction and key informant interviews. A multilevel coding scheme is used to organize the data into a matrix along key domains, which is then reviewed and verified by the key informants.

PRINCIPAL FINDINGS

This instrument can usefully differentiate between and among Medicaid fee-for-service programs and Medicaid managed care plans along key domains of interest. Beyond documenting basic features of the plans and providing contextual information, these data will support the refinement and testing of hypotheses about the impact of public sector managed care on access, quality, costs, and outcomes of care.

CONCLUSIONS

If managed behavioral health care research is to advance beyond simple case study comparisons, a well-conceptualized set of instruments is necessary.

Students with mental illnesses in a university setting: faculty and student altitudes, beliefs, knowledge, and experiences

Over the last decade, the topic of post-secondary supported education for people with severe and persistent mental illnesses has gained increasing attention and sparked interest in what colleges and universities can do to assist individuals with mental illnesses to achieve their educational goals. The purpose of this article is to discuss the issue and describe one university's strategy for improving the educational environment of students with psychiatric disabilities. We present findings from a survey designed to assess faculty and student attitudes, beliefs, knowledge, and experiences with students identified as having a mental illness.

Florida's Medicaid mental health carve-out: lessons from the first years of implementation

Florida, like many other states, has embarked on an experiment with managed mental health care for Medicaid enrollees. Under a 1915(b) waiver, the state's Medicaid agency began a mental health carve-out demonstration in March 1996 in the Tampa Bay area. This qualitative case study seeks to ascertain the impact of the carve-out (and, by comparison, HMO arrangements) on the public mental health sector. Findings suggest that the carve-out demonstration has succeeded in creating a fully integrated mental health delivery system with financial and administrative mechanisms that support a shared clinical model. However, other findings raise concerns about the HMO model in terms of stability, access to care, efficiency, and more generally about the shifting of risk and public responsibility "downstream" to private organizations without sufficient governmental oversight. These findings may offer guidance for other states implementing major managed care policy initiative for disabled Medicaid enrollees.

Incompetency and insanity: feasibility of community evaluation and treatment

In order to examine the feasibility of doing more sanity and competency evaluations and treatment on an outpatient basis rather than at a state hospital, we gave a feasibility questionnaire to 288 CMHC and state hospital administrators and treatment staff members. The respondents indicated that, given enhanced community evaluation and treatment programs for forensic clients, (a) 41 percent of the sanity evaluations and 45 percent of the competency evaluations done at the hospital could be done in local communities, (b) 35 percent to 38 percent of the clients found incompetent could be treated in local communities, and (c) 39 percent to 50 percent of the clients found insane could be released to outpatient treatment six months earlier than presently. Other findings indicated several specific improvements needed in the community mental health system before it can properly handle more forensic clients.