PERSPECTIVE: Health Economic Interests at NIMH and NIDA to Improve Delivery of Behavioral Health Services

BACKGROUND

Effective financing mechanisms are essential to ensuring that people can access and utilize effective treatments and services. Financing mechanisms are needed not only to pay for the delivery of those treatments and services, but also ancillary costs, while also keeping care affordable.

AIMS

This article highlights key areas of the interest of the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) in supporting applied health economics and health care financing research. Specifically, this article discusses the long-range impact of NIH's earlier investments in applied health economics research, and NIH's ongoing efforts to communicate its interests in health economics research. We discuss the 2023 NIMH-NIDA-sponsored health economics conference, and the ideas presented there for developing and assessing innovative behavioral health care financing models; three of the presented papers were recently published in the Journal of Mental Health Policy and Economics.

METHODS

We describe the history and impact of NIMH- and NIDA-sponsored economic research and identify current research interests as identified in the NIMH and NIDA Strategic Plans and recent funding announcements. We examine themes presented at the NIMH-NIDA Health Economics conference. The conference included over 300 participants from 20 countries, from six continents.

RESULTS

The topics highlighted at the conference highlight the ways in which NIH-funded research has promoted the development of innovative health care financing methods, both from the supply side (e.g., providers and payers) and demand side (e.g., service users and families). Invited speakers discussed the findings from NIH-supported research in the topic areas of payment and financing, behavioral economics and social determinants of health. Keynote speakers highlighted emerging topics in the field, including the economics of health equity, biases in mental health models in health care, and value-based insurance design.

DISCUSSION

We demonstrate a resurgence of and explicit interest in health economics and policy research at NIMH and NIDA. However, more work is needed in order to design funding mechanisms that fully provide access to and facilitate use of effective evidence-based practices to improve mental health outcomes. For example, it is important that policy and health economic research projects include decision makers who will be the end users of data and study results, to ensure that results can be meaningfully put into practice.

IMPLICATIONS FOR HEALTH CARE

Designing effective and efficient funding mechanisms can help ensure that service users have access to effective treatments and that clinicians and provider organizations are adequately compensated for their work.

IMPLICATIONS FOR HEALTH POLICIES

Federal, state, and local policies, as well as policies of payers and health care organizations, can influence the type of care that is supported and incentivized.

IMPLICATIONS FOR FURTHER RESEARCH

As demonstrated by the research interests as outlined in their respective Strategic Plans and funding announcements, NIMH and NIDA continue to fund health economic and policy research that aims to improve health care access, quality and outcomes for people with or at risk of developing behavioral health conditions in the US and around the world.

PERSPECTIVE: Current US COVID-19 Pandemic Substance Use Research and Ideas for Research That May Help Us Learn More

BACKGROUND

The COVID-19 pandemic likely had and will continue to have severe implications for those who use addictive substances, have substance use disorders, or use substance use related health care services. Policy and services research, particularly health economics research, can illuminate these effects on individuals, uncover the effects of the rapidly imposed changes in policy on how services were delivered, promote efficient and effective provision of services, and inform responses to future pandemics.

AIMS OF THE STUDY

To identify potential substance use related effects of COVID-19 and pandemic mitigation policies, highlight themes in current research, and suggest areas for further high-quality policy and services research, with an emphasis on health economics research.

METHODS

Review of recent published commentaries, government documents, and initial research findings to describe potential impacts, and review of current COVID-19 related research grants funded by the United States National Institutes of Health to identify themes.

RESULTS

Potential impacts include increased risk for and severity of COVID-19 illness among those who use substances, mitigation measures causing increased substance use and development of use disorders, and fundamental changes in the way treatment is provided. Current research may provide initial findings that may be useful in generating hypotheses for future rigorous research.

DISCUSSION

Research on these and other areas could enhance our fundamental understanding of the needs of individuals who use substances and how to best address those needs in the most efficient, effective way. Though this brief review highlights some areas of potential interest, its focus is mainly on treatment and on the United States context. Research on additional services and contexts likely could inform advances as well.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

Health care providers rapidly and under considerable stress made needed changes that likely mitigated SARS-CoV-2 transmission. Rigorous research can help determine what worked best and for whom, what could be kept, and what might better be discarded.

IMPLICATIONS FOR HEALTH POLICIES

Research on the effects of mitigation policies may inform the development of policies to reduce negative effects when addressing future pandemics, whether to permanently allow at least some substance use treatment flexibilities, and whether research on other restrictive policies might lead to improvement.

IMPLICATIONS FOR FURTHER RESEARCH

This extraordinary event brought into sharp relief the numerous vulnerabilities of those who use substances and those with substance use disorders while also leading to vast changes in the services that address them. Rigorous research into those effects could result in significant improvements in policy and practice.

Economic analysis in behavioral health: Toward application of standardized methodologies

Health care remains the most expensive sector in the U.S. economy, now accounting for nearly 1 in every 5 dollars spent. The purpose of health care is to improve the health of populations. However, formal medical care is one of many alternatives for improving health. In order to make better use of scarce resources, cost-effectiveness methodologies have been developed to evaluate how to produce the most health within the constraints of available resources. Standardized cost-effectiveness methodologies are now commonly used in the evaluation of medical therapies and new technologies. However, these methods have rarely been employed for the evaluation of behavioral interventions. Behavioral interventions often use measures that are not generally applied in other areas of health outcomes research. A consequence of neglecting to employ standardized cost-effectiveness analysis is that behavioral, psychological, and environmental interventions may be left out of resource allocation discussions. The purpose of this paper is to review standardized approaches to cost-effectiveness analysis and to encourage their use for the evaluation of behavioral intervention programs. Application of standardized methods of cost-effectiveness analysis will allow direct comparisons between investing in behavioral interventions programs in comparison to a wide range of other alternatives. The methods are general and can be used to estimate the cost-effectiveness of social and environmental interventions in addition to traditional medical and surgical treatments. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Formal Treatment, Self-Help, or No Treatment for Alcohol-Use Disorders? Evidence from the National Household Survey on Drug Abuse

OBJECTIVE

The purpose of this study was to examine further alcohol treatment choice by using data from a nationally representative sample of adults with alcohol-use disorders to test which of three models-sequential, multinomial, or nested best fit the data. The goals were to provide evidence about how this choice was made and to provide improved coefficient estimates, as well as to inform future analyses of treatment choice.

METHOD

Data from the 2000 National Household Survey of Drug Abuse include respondents ages 18-64 reporting symptoms consistent with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of alcohol abuse or dependence. A nested multinomial framework is used to determine the preferred model and to estimate the effect of respondents' characteristics on the decisions to receive help and what kind of help to receive.

RESULTS

A sequential model, in which the choice of whether to receive help is unaffected by the level of satisfaction afforded by the alternatives, best fit the data. Older respondents had higher odds of both receiving help and choosing self-help, and those with a DSM-IV diagnosis of abuse had lower odds of receiving help but higher odds of entering self-help.

CONCLUSIONS

The decision to receive help for alcohol problems appears unaffected by the perceived differences between these two broad categories of alternatives: self-help or formal treatment. This result may indicate the need to provide more information on the full range of treatment options to those for whom self-help may not be sufficient.

Graduate medical education costs in nonacademic health center teaching hospitals: evidence from Maryland

As managed care has grown, much concern has been expressed about the potential plight of the nation's 125 academic health centers (AHCs). Less concern has focused on non-AHC teaching hospitals, although most studies of graduate medical education (GME) costs include these hospitals in their estimates. While most studies have found that costs increase positively with various measures of "teaching intensity," some have concluded that hospitals with smaller programs have costs that are the same or less than comparable nonteaching hospitals. However, few studies have tested whether AHCs' cost structures are sufficiently similar to those of other hospitals to reliably include them in the same estimation. This article tests that assumption for Maryland hospitals, finds it violated, and presents results for non-AHC teaching hospitals. The results reveal that, at least in Maryland, even small teaching programs add to hospital costs.

Patterns of decline among inpatient procedures

This paper explores how the new financial incentives and organizational structures that prevail in the hospital industry have affected the mix of services provided by hospitals. Using data from the Agency for Health Care Policy and Research's Healthcare Cost and Utilization Project, the authors studied the 150 procedures that were most frequently performed on inpatients in 1980. They found that (a) 37 of the 150 procedures declined in use more than 40 percent by 1987, (b) patients that continued to receive one of the 37 procedures in 1987 on an inpatient basis tended to be more severely ill than in 1980, and (c) rates of decline were disproportionately large for Medicaid recipients. Three main factors have contributed to the decline in inpatient use of these procedures. Most important has been the shift from inpatient to outpatient settings, a result of new technologies and pressures from reimbursement mechanisms and utilization review policies. Some procedures have been replaced by less invasive, more effective approaches. Other procedures are now considered ineffective by the medical community and have been largely abandoned as a result.

Hospitals with chronic financial losses: what came next?

Hospitals with chronic losses might respond by closing, by drastically changing their services and patient mix, or by increasing efficiency. These possible responses are examined by studying a cohort of hospitals that were losing money between 1980 and 1984 as measured by their five-year average total revenue margins. These "negative-cohort" hospitals were followed through 1988 to see if they survived, and if they did, what changes they made. Only about 10 percent of hospitals in the negative cohort closed. The remainder did not alter their service mix or select in favor of easier, better-paying patients. However, there was a reduced rate of investment in new technologies.

The protracted demise of medical technology. The case of intermittent positive pressure breathing

In this study, the effects of hospital, staff, and patient characteristics on the rates of use and abandonment of an outmoded medical technology, intermittent positive pressure breathing (IPPB) are analyzed. The study focuses specifically on the use of IPPB to treat inpatients with chronic obstructive pulmonary disease in a national sample of more than 500 community hospitals from 1980 to 1987. Cross-sectionally, hospitals with shorter case-mix-adjusted lengths of stay, private nonprofit or investor-owned hospitals, and hospitals located outside of the north central United States were more likely to abandon IPPB by 1980. Teaching status, location, ownership, volume, and source of payment all appeared to affect rates of IPPB use in 1980. The longitudinal analysis examines both the probability a hospital abandoned IPPB and declines in rates of IPPB use over the study period, conditioned on the availability of IPPB in 1980. The results show that changes in the characteristics of hospitals, patients, and physicians all help to explain variations in the abandonment of IPPB. These findings contrast with previous studies of technological change, which find hospital size to be the most important variable. Size is important in explaining the rate of use in 1980, but it has no effect on the rate of decline in use or abandonment after 1980. In general, the analysis demonstrates that a combination of factors, economic incentives as well as information, contribute to the abandonment of outmoded medical technologies. Given the surprisingly long time periods required for this process to occur, the analysis underscores the need to strengthen financial incentives that encourage appropriate medical decisions and to disseminate information about the efficacy of specific procedures more widely and effectively.