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

The Hungarian Care Managing Organization Pilot Program

OBJECTIVES

The aim of this article was to provide a description of the Hungarian care managing organization (CMO) pilot program and its environment, incentive structure, and preliminary outcomes. The need to change the behavior of doctors to increase the effectiveness and cost-effectiveness of the system was the key rationale for the Hungarian CMO pilot program.

METHODS

After an application process, nine CMOs were entitled to enter into the system in July 1999. By 2006, there were 14 CMOs covering 2.1 million people. The Hungarian CMO program tried to combine the advantages of both the US managed care programs and the UK general practitioner fundholding system, within the constraints and opportunities of a Central-European country committed to a single-payer health insurance system.

RESULTS

The revenue of CMOs derived from a risk-adjusted capitation. The capitation formula was weighted only by age and sex. The expenditures of the CMOs included all the health expenditures on their patients that occurred in any part of the health care system. The average savings rate for all CMOs for the fiscal years 1999 to 2007 was 4.94%. The highest rates of savings were realized in chronic and acute inpatient care and medical devices. The pilot was discontinued in 2008 without a comprehensive evaluation of the experience.

CONCLUSIONS

We can conclude that this pilot had a significant contribution to the modernization of the Hungarian health care system.

Validity of Clinician's Self-Reported Practice Elements on the Monthly Treatment and Progress Summary

An increased demand for accountability in community mental health systems has resulted in a need for valid, reliable measures of therapeutic practice. The Monthly Treatment and Progress Summary (MTPS), developed through the Hawaii Child and Adolescent Mental Health Division, is a clinician-report measure that describes therapeutic practices, treatment targets, and progress ratings for each treatment case. The current study evaluated the validity of the therapeutic strategies reported on the MTPS by comparing coder- and clinician-reported use of practices. Using 47 audio recordings from 19 youths' therapy sessions, trained observers reliably coded 12 discrete practices. Four of the 12 practices were found to be valid according to clinician-coder agreement (intraclass correlations ≥0.60). The coding system was revised, utilizing extensiveness and experiential scales, and 100 % of practices were valid according to clinician-coder agreement. Practical use of the MTPS, implications for service systems, and future directions for research on the MTPS are discussed.

Peer influences on adolescent alcohol and other drug use outcomes

PURPOSE

To examine the role of family environment and peer networks in abstinence outcomes for adolescents 1 year after intake to alcohol and other drug (AOD) treatment.

DESIGN

Survey of 419 adolescents 13 to 18 years of age at consecutive intakes to AOD treatment programs at four sites of a large health system, with telephone follow-up survey 1 year after intake.

METHODS

Examined association of 1-year abstinence with baseline characteristics. Using logistic regression, we examined characteristics predicting 1-year abstinence and predicting having fewer than four substance-using friends at 1 year.

RESULTS

We found that family environment scores related to family conflict, limit setting, and positive family experiences, were not related to abstinence outcomes, but peer networks were related. Adolescents with fewer (less than four) AOD-using friends were more likely to be abstinent than those with four or more AOD-using friends (65% vs. 41%, p= .0002). Having fewer than four AOD-using friends at intake predicted abstinence at 1 year (odds ratio [OR]= 2.904, p= .0002) and also predicted having fewer than four AOD-using friends at 1 year (OR= 2.557, p= 0.0007).

CONCLUSIONS

Although family environment is an important factor in the development of AOD problems in adolescents, it did not play a significant role in treatment success. The quality of adolescent peer networks did independently predict positive outcomes.

CLINICAL RELEVANCE

For physicians, advanced practice registered nurses, and other primary and behavioral care providers who screen and care for adolescents with AOD and other behavioral problems, our finding suggest the importance of focusing on improving the quality of their peer networks.

Organizational factors and depression management in community-based primary care settings

BACKGROUND

Evidence-based quality improvement models for depression have not been fully implemented in routine primary care settings. To date, few studies have examined the organizational factors associated with depression management in real-world primary care practice. To successfully implement quality improvement models for depression, there must be a better understanding of the relevant organizational structure and processes of the primary care setting. The objective of this study is to describe these organizational features of routine primary care practice, and the organization of depression care, using survey questions derived from an evidence-based framework.

METHODS

We used this framework to implement a survey of 27 practices comprised of 49 unique offices within a large primary care practice network in western Pennsylvania. Survey questions addressed practice structure (e.g., human resources, leadership, information technology (IT) infrastructure, and external incentives) and process features (e.g., staff performance, degree of integrated depression care, and IT performance).

RESULTS

The results of our survey demonstrated substantial variation across the practice network of organizational factors pertinent to implementation of evidence-based depression management. Notably, quality improvement capability and IT infrastructure were widespread, but specific application to depression care differed between practices, as did coordination and communication tasks surrounding depression treatment.

CONCLUSIONS

The primary care practices in the network that we surveyed are at differing stages in their organization and implementation of evidence-based depression management. Practical surveys such as this may serve to better direct implementation of these quality improvement strategies for depression by improving understanding of the organizational barriers and facilitators that exist within both practices and practice networks. In addition, survey information can inform efforts of individual primary care practices in customizing intervention strategies to improve depression management.

A survey of the infrastructure for children's mental health services: implications for the implementation of empirically supported treatments (ESTs)

A structured interview survey of directors of a large national sample (n = 200) of mental health service organizations treating children examined the governance, financing, staffing, services, and implementation practices of these organizations; and, director ratings of factors important to implementation of new treatments and services. Descriptive analyses showed private organizations financing services with public (particularly Medicaid) funds are prevalent and that employment of professional staff, clinical supervision and training, productivity requirements, and outcomes monitoring are common. Results of random effects regression models (RRMs) evaluating associations between governance, financing, and organizational characteristics and the use of new treatments and services showed for-profit organizations more likely to implement such treatments, and organizations with more licensed clinical staff and weekly clinical supervision in place less likely to do so. Results of RRMs evaluating relations between director ratings of the importance to new treatment and service implementation of three factors-fit with existing implementation practices, infrastructure support, and organizational mission and support-suggest greater importance to public than private organizations of these factors. Implications for EST implementation and future research are described.

A typology of organizational and contractual arrangements for purchasing and delivery of behavioral health care

The evolution of behavioral health care financing and delivery has led to a wide variety of arrangements connecting consumers to behavioral health services. In this paper, we present a typology based on three distinguishing features of behavioral health arrangements along which there is a high degree of variability and this variability has been shown to affect the cost and quality of behavioral health care: (1) the extent to which sponsor oversight over care is outsourced by way of contracts rather than performed directly; (2) whether financing for behavioral health is partitioned from health care financing overall; and (3) the amount of financial risk shared by the sponsor with third parties.

Is conventional wisdom wrong? Coverage for substance abuse treatment under Medicaid managed care

Conventional wisdom suggests that coverage for substance abuse treatment under Medicaid is generally poor, and that access to care may be reduced when control over behavioral health services is given to private health plans, such as those under Medicaid managed care. To examine this premise, this study reports on a cross-sectional comparative survey of state Medicaid managed care programs conducted in the year 2000. Although not all states provided substance abuse benefits under their Medicaid programs, our findings suggest that a majority of states used managed care arrangements to provide substance abuse treatment, with most providing an array of covered services. Most Medicaid behavioral health plans were fully capitated. The number of comprehensive health plans providing substance abuse services was slightly higher than the number of behavioral health carveouts. About half of the waiver programs that covered substance abuse treatment covered methadone maintenance, but waiver programs employing comprehensive health plans were more likely to provide coverage for methadone maintenance.