Cost and quality trends under managed care: is there a learning curve in behavioral health carve-out plans?

Impacts of an Integrated Medicaid Managed Care Program for Adults with Behavioral Health Conditions: The Experience of Illinois

This study assessed the impact of the Integrated Care Program (ICP), a new Medicaid managed care model in Illinois, on health services utilization and costs for adults with behavioral health conditions. Data sources included Medicaid claims, encounter records, and state payment data for 28,127 persons with a behavioral health diagnosis. Difference-in-differences models, in conjunction with propensity score weighting, were used to compare utilization and costs between ICP enrollees and a fee-for-service (FFS) comparison group. The model considered the impact of the SMART Act, which restricted access to care for the comparison group. Before the SMART Act, ICP was associated with 2.8 fewer all-cause primary care visits, 34.6 fewer behavioral health-specific outpatient visits, and 2.5 fewer all-cause inpatient admissions per 100 persons per month, and $228 lower total costs per member per month relative to the FFS group. After the SMART Act, ICP enrollees had increased outpatient and dental services utilization without significantly higher costs. The relative increase in utilization was due primarily to decreased utilization in the restricted FFS group after the SMART Act. By the end of the study period, the ICP group had 13.3 more all-cause primary care visits, 1.5 more emergency department visits, and 1.4 more dental visits per 100 persons per month relative to the FFS program. A fully-capitated, integrated managed care program has the potential to reduce overall Medicaid costs for people with behavioral health conditions without negative effects on service utilization.

The Role of Learning in Health Technology Assessments: An Empirical Assessment of Endovascular Aneurysm Repairs in German Hospitals

Changes in performance due to learning may dynamically influence the results of a technology evaluation through the change in effectiveness and costs. In this study, we estimate the effect of learning using the example of two minimally invasive treatments of abdominal aortic aneurysms: endovascular aneurysm repair (EVAR) and fenestrated EVAR (fEVAR). The analysis is based on the administrative data of over 40,000 patients admitted with unruptured abdominal aortic aneurysm to more than 500 different hospitals over the years 2006 to 2013. We examine two patient outcomes, namely, in-hospital mortality and length of stay using hierarchical regression models with random effects at the hospital level. The estimated models control for patient and hospital characteristics and take learning interdependency between EVAR and fEVAR into account. In case of EVAR, we observe a significant decrease both in the in-hospital mortality and length of stay with experience accumulated at the hospital level; however, the learning curve for fEVAR in both outcomes is effectively flat. To foster the consideration of learning in health technology assessments of medical devices, a general framework for estimating learning effects is derived from the analysis. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.

Forgetting the learning curve for a moment: how much performance is unrelated to own experience?

Volume-outcome relationships are of clear importance for most participants in the health-care industry; research and appropriate policy implications are of critical importance. In this letter we critique the prevailing 'learning-by-doing' view in cardiac surgery. We illustrate the very wide disparity in empirical findings on volume-outcome relationships there, in the context of broader open issues in 'learning curves' in general. Potential complementary mechanisms, e.g. 'social learning by knowledge spillovers' are introduced; these cast into doubt the prevailing policy recommendations of simple regionalization and volume smoothing.

Driving with roadmaps and dashboards: using information resources to structure the decision models in service organizations

This paper illustrates the application of design principles for tools that structure clinical decision-making. If the effort to implement evidence-based practices in community services organizations is to be effective, attention must be paid to the decision-making context in which such treatments are delivered. Clinical research trials commonly occur in an environment characterized by structured decision making and expert supports. Technology has great potential to serve mental health organizations by supporting these potentially important contextual features of the research environment, through organization and reporting of clinical data into interpretable information to support decisions and anchor decision-making procedures. This article describes one example of a behavioral health reporting system designed to facilitate clinical and administrative use of evidence-based practices. The design processes underlying this system-mapping of decision points and distillation of performance information at the individual, caseload, and organizational levels-can be implemented to support clinical practice in a wide variety of settings.

Managed care organizations' use of treatment management strategies for outpatient mental health care

A nationally representative sample of managed care organizations was surveyed (response rate=92%) regarding use of treatment management techniques for outpatient mental health care in their commercial products in 1999. Bivariate tests and logistic regression models were used to examine the relationship between product type, behavioral health contracting arrangement and treatment management techniques (prior authorization, standards for time to initial appointment, concurrent review, standards for follow-up after discharge, case management, practice guidelines). Prevalence varied from 43% to 87% depending on the technique. HMO products and products with specialty behavioral health contracts were more likely to use the techniques. Product type and contracting arrangement had independent effects.

Incentives in a Medicaid carve-out: impact on children with special health care needs

OBJECTIVE

To evaluate whether a specialty care payment "carve-out" from Medicaid managed care affects caseloads and expenditures for children with chronic conditions.

DATA SOURCE

Paid Medicaid claims in California with service dates between 1994 and 1997 that were authorized by the Title V Children with Special Health Needs program for children under age 21.

STUDY DESIGN

A natural experiment design evaluated the impact of California's Medicaid managed care expansion during the 1990s, which preserved fee-for-service payment for certain complex medical diagnoses. Outcomes in time series regression include Title V program participation and expenditures. Multiple comparison groups include children in managed care counties who were not mandated to enroll, and children in nonmanaged care counties.

DATA COLLECTION/EXTRACTION METHODS

Data on the study population were obtained from the state health department claims files and from administrative files on enrollment and managed care participation.

PRINCIPAL FINDINGS

The carve-out policy increased the number of children receiving Title V-authorized services. Recipients and expenditures for some ambulatory services increased, although overall expenditures (driven by inpatient services) did not increase significantly. Cost intensity per Title V recipient generally declined.

CONCLUSIONS

The carve-out policy increased identification of children with special health care needs. The policy may have improved children's access to prevailing standards of care by motivating health plans and providers to identify and refer children to an important national program.

Computer-supported monitoring of patient treatment response

The use of information technology (IT) for the purpose of improving psychotherapy outcomes in the context of routine clinical practice is described. IT efforts from two research programs, one in Germany and the other in the United States, are based on evidence that not all patients who enter treatment have a positive outcome and that continuous monitoring of patient treatment response with immediate feedback to therapists can be used to increase the likelihood of success for the poorly responding client. Such monitoring and feedback can best be accomplished by IT methodologies. Suitable IT systems are described, and their strengths and limitations are highlighted. Evidence is presented that supports the positive value of such efforts for improving patient treatment response.

Changes in managed care activity in outpatient substance abuse treatment organizations, 1995-2000

Using nationally representative data from 1995 and 2000, this study examines trends in managed care penetration and activity among outpatient drug treatment organizations in the United States. Further, it investigates how managed care activity varies across different types of treatment providers and for public and private managed care programs. Overall, managed care activity has increased, with a greater proportion of units having managed care arrangements and a larger percentage of clients covered by managed care. In general, public managed care activity has increased and private managed care activity has decreased. Treatment providers report that they have fewer managed care arrangements, which may reflect consolidation in the managed behavioral care sector. Finally, growth in managed care among outpatient substance abuse treatment units affiliated with hospitals and mental health centers may signal a preference for providers that can effectively link substance abuse treatment with medical and social service provision, or, alternatively, that linkages with such organizations may provide the size necessary to assume the risks associated with managed care contracts.

Adverse selection and generosity of alcohol treatment benefits

Concerns about attracting disproportionate numbers of employees with alcohol problems limit employers' willingness to offer health plans with generous alcohol treatment benefits. This paper analyzes two potential avenues of adverse selection, namely biased enrollment into plans and biased exit from plans offered by 57 employers between 1991 and 1997. We compare alcohol treatment use rates and costs of new and old enrollees between more generous and less generous plans; we also analyze disenrollment rates and enrollment duration by plan generosity for users and nonusers of alcohol treatment services. To avoid confounding benefit generosity with other plan features, in particular the use of managed care mechanisms, we compare plans that were administered in the same way by a large managed behavioral health care organization. Overall, we find no evidence of adverse selection into more generous plans. Contrary to the selection hypothesis, treatment costs of new members compared to old members are lower in firms with more generous treatment benefits than in firms with more limited benefits. Also, users of alcohol treatment services do not remain disproportionately enrolled longer in plans with generous benefits.

Specialty health care, treatment patterns, and quality: the impact of a mental health carve-out on care for depression

OBJECTIVES

To assess the effect of a mental health carve-out on treatment patterns and quality of care for outpatient treatment of depression.

DATA SOURCES

Outpatient and pharmaceutical claims from September 1993 through March 1997 for one large managed care organization in the Midwest that carved-out mental health and substance abuse benefits in September 1995.

RESEARCH DESIGN

Using the treatment episode as the unit of analysis (n = 1,747), changes in treatment patterns associated with the change to a carve-out were evaluated. Logistic regression was used to assess whether in the postperiod a treatment episode was more likely to be treated with (1) an antidepressant and (2) a type and intensity of treatment with proven efficacy. To strengthen confidence in a causal relationship, I search for structural breaks in treatment patterns across a wide range of dates, assuming no a priori knowledge of the timing of the impact of the carve-out.

RESULTS

I find the carve-out to be associated with an increase in the use of drug treatments. Although I find a decrease in the use of guideline-level treatment over the entire study period, there is an increase in the number of episodes treated with guideline-level treatment over what would be the case in the absence of the carve-out.

CONCLUSIONS

The increase in the use of drug treatments suggests previous research that excluded these costs may have overestimated the savings attributable to carve-outs. Guideline-level care appeared to increase as a result of carve-out implementation suggesting the use of management and specialization to reduce costs is not antithetical to quality improvement.

Quality measurement and accountability for substance abuse and mental health services in managed care organizations

OBJECTIVES

To analyze managed care organizations' (MCOs') use of behavioral health quality management activities using nationally representative survey data.

MATERIALS AND METHODS

The primary data source is the Brandeis Survey on Alcohol, Drug Abuse, and Mental Health Services in MCOs. Using a sampling strategy designed for national estimates, we surveyed 434 MCOs in 60 market areas (response rate = 92%) regarding their commercial products' behavioral health services in 1999. Of these, 417 MCOs reported clinically oriented information for 752 products. We investigated the use of four behavioral health quality management activities: patient satisfaction surveys, clinical outcomes assessment, performance indicators, and practice guidelines. chi tests and logistic regression were used to determine effects of product type (HMO, PPO, point-of-service) and behavioral health contracting arrangement (specialty contract, comprehensive contract including general medical and behavioral health, internal provision).

RESULTS

Three-quarters of products used patient satisfaction surveys (70.1%), performance indicators (72.7%), and practice guidelines (73.8%) for behavioral health. Under half (48.9%) assessed clinical outcomes. HMO products were most likely, and PPOs least likely, to conduct activities. Quality activities were significantly more common among specialty-contract products. Logistic regression showed significant negative effects on quality activity use for PPO and POS products compared with HMOs. For clinical outcomes, specialty- and comprehensive-contract arrangements had significant positive effects. There were interactions between product type and contract arrangement.

CONCLUSIONS

Most commercial managed care products use patient satisfaction surveys, performance indicators, and practice guidelines for behavioral health, whereas clinical outcomes assessment is less common. Product type and contracting arrangements significantly affect use of these activities.

Learning and the evolution of medical technologies: the diffusion of coronary angioplasty

This study uses longitudinal data on patients receiving percutaneous transluminal coronary angioplasty (PTCA) to examine changes in outcomes and costs. All hospitals achieved substantial reductions in inpatient mortality and emergency bypass surgery over time, regardless of the number of procedures performed. Annual hospital procedure volume was also associated with improved outcomes, although the effect is small. There was no evidence that learning by doing (cumulative PTCA volume) influenced outcomes. The high correlation between annual and cumulative procedure volume precludes a point estimate of the effect of learning by doing on costs, although the upper bound on the potential learning effect is sizeable. The results suggest that centralizing provision of PTCA may lead to lower costs, but only small outcomes improvements.

The impacts of mental health parity and managed care in one large employer group

We examine the impacts of a state mental health parity mandate on a large employer group, which simultaneously introduced a managed behavioral health care carve-out. Overall, we find that mental health/substance abuse (MH/SA) costs dropped 39 percent from the year prior to three years after parity, with managed care offsetting increases in demand induced by parity coverage. Managed care was most effective in reducing very high inpatient use among adolescents and children. The effect of the parity mandate on access was ambiguous: While treatment prevalence rose nearly 50 percent, similar increases were observed for groups not subject to the mandate.

Changes in inpatient psychiatric utilization and quality of care performance measures in a capitated HMO population, 1989-1999

Managed behavioral health care approaches have significantly reduced inpatient utilization and related cost of care, but the relationship between decreased utilization and cost of care to changes in quality of care performance over time remains in question. The trends in utilization and quality of care performance measures over the course of 10 years of the Tufts Health Plan Designated Facility Program, a model health maintenance organization capitated program for inpatient behavioral health care, are presented. The results indicate that substantial decreases in inpatient utilization were sustained while quality of care measures improved over time. The data support the Tufts Health Plan Designated Facility Program as a successful means of balancing cost containment with quality of care.

Why carve out? Determinants of behavioral health contracting choice among large U.S. employers

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

Tracking changes in behavioral health services: how have carve-outs changed care?

This special issue of the Journal of Behavioral Health Services & Research on mental health carve-outs brings together some of the latest research on recent policy and market changes affecting behavioral health services. This introductory article provides background information about carve-outs and the managed behavioral health care industry. This article also reviews prior research in the mental health carve-out field.