Identifying indicators of community participation-promoting efforts within coordinated specialty care: A modified e-Delphi study of stakeholder perspectives.

AIM: Community participation in occupational, social, recreational, and other domains is critically important during young adulthood. Coordinated Specialty Care (CSC) programs provide developmentally tailored care to young adults experiencing early psychosis within the United States, but little is known about the breadth of efforts to promote community participation. This study aimed to develop and evaluate indicators of these efforts based on the perspectives of a national multi-stakeholder group. METHODS: Seventeen stakeholders (i.e., young adults with early psychosis, family members, experts by profession) participated in a modified e-Delphi study, conducted in two rounds. The purpose of round one was to generate a comprehensive list of community participation-promoting indicators. During round two, stakeholders rated the importance and feasibility of the implementation of each indicator. Descriptive statistics and percentage of agreement regarding round two ratings were assessed. RESULTS: During round one, 186 indicators of activities and/or practices designed to promote community participation were identified; this list was reduced to 44 by eliminating redundancies or indicators not related to community participation. In round two, we found broad agreement regarding the importance, but significant variation in perceived feasibility of indicators. The highest-rated indicators in both categories pertained to staff knowledge (regarding barriers and supports to participation and the importance of participation to health) and strategies for addressing participation barriers. CONCLUSIONS: This study is expected to facilitate the identification and development of promising CSC activities and practices designed to promote community participation among young adults while potentially also enhancing engagement in services and improving clinical outcomes.

Financing Mechanisms for Reducing Adversity and Enhancing Resilience Through Implementation of Primary Prevention.

The experience of adversity and toxic stress in childhood is associated with the development of chronic health and behavioral health problems. These problems contribute substantially to health care expenditures and the overall burden of disease. Although a strong scientific literature documents the effectiveness of primary prevention in reducing childhood adversity, promoting well-being and lessening the incidence of negative outcomes, funding for these interventions is highly fragmented across multiple government agencies as well as private and philanthropic sectors. It is becoming increasingly clear that improving population health will require a concentrated public health effort to improve access to and the accountability of these interventions as well as the development of novel financing schemes. In this perspective we review existing financing mechanisms for funding interventions known to reduce adverse childhood experiences and discuss innovative financing approaches that use insurance as well as pay-for-success funding mechanisms. The latter require that cost savings associated with primary prevention be quantified and that these savings be used to offset program costs, sometimes with a return on investment for private investors. We provide a series of recommendations regarding better coordination and strategic oversight of existing resources as well as the need to further develop and validate methodologies for estimating the societal costs and benefits associated with the varying social policies that are designed to ameliorate the effects of adversity and to build resilience.

Toxic stress, behavioral health, and the next major era in public health.

Before the development of the germ theory in the late 19th century, infectious illnesses were largely uncontrollable and caused significant mortality. Implementing public hygiene, preventive, and treatment interventions created remarkable improvements in population health. Today's U.S. public health crises involve threats to health and human capital evidenced by multiple indicators of deteriorating wellbeing. These problems result from the interaction of risk and protective factors. Specifically, we argue that the interaction of genetic vulnerability and toxic stress are antecedents to a developmental cascade that undermines healthy development and human capital. We review relevant literature, summarize effective strategies to prevent or ameliorate this deterioration, and outline a theory of the mechanisms currently undermining our health. A series of strategies that we believe will constitute the next major era in public health are discussed, involving actions at the individual/family, community and societal level to reduce risk and strengthen protective factors. (PsycINFO Database Record

Comparative effectiveness research in mental health: an advocate's perspective.

Comparative effectiveness research holds great promise for improving the care of people with mental health conditions and disorders related to substance abuse. But inappropriate application of such research can threaten the quality of that care. We examine the controversy surrounding a large real-world trial of schizophrenia treatments and conclude that the initial presentation of results led to overly simplistic policy suggestions that had the potential to harm patients. Patient advocacy groups helped illuminate these consequences and helped stimulate further discussion and analysis. Researchers must engage stakeholders, especially patients, in all aspects of comparative effectiveness research and translate the findings into sound mental health policy and practice.

STAR*D: helping to close the gap between science and practice.

Practical clinical trials, such as STAR*D (Sequenced Treatment Alternatives to Relieve Depression), extend the traditional randomized controlled trial to real-world settings. Consumers and clinicians should be encouraged by STAR*D's 70% remission rate and should realize that for many participants remission required medication switching and augmentation. Policy makers should recognize the importance of easy access to a full range of treatments. Researchers should be sobered by the high attrition rate and the 30% of participants who did not achieve remission. Although more such practical trials are needed, future work must more meaningfully involve consumers in design, analysis, and interpretation.

After parity--what's next.

A new law prohibiting unequal treatment limits and financial requirements for mental health and substance abuse (MH/SA) benefits establishes critical protections for 113 million Americans. The new parity law doesn't mandate coverage for MH/SA treatment and anticipates management of the benefit. Given these features, clear regulations mapping the intent of the law are critical. Education regarding the costs of untreated or ineffectively treated MH/SA conditions is needed to encourage comprehensive coverage, because academic performance and worker productivity are at stake. As health care reform proceeds, we must use the new law to reinforce the centrality of mental health to overall health.

Lessening Homelessness Among Persons with Mental Illness: A Comparison of Five Randomized Treatment Trials.

We evaluate the influence of housing, services, and individual characteristics on housing loss among formerly homeless mentally ill persons who participated in a five-site (4-city) study in the U.S. Housing and service availability were manipulated within randomized experimental designs and substance abuse and other covariates were measured with a common protocol. Findings indicate that housing availability was the primary predictor of subsequent ability to avoid homelessness, while enhanced services reduced the risk of homelessness if housing was also available. Substance abuse increased the risk of housing loss in some conditions in some projects, but specific findings differed between projects and with respect to time spent in shelters and on the streets. We identify implications for research on homeless persons with mental illness that spans different national and local contexts and involves diverse ethnic groups.

Medicaid managed care and the distribution of societal costs for persons with severe mental illness.

OBJECTIVE: Managed care financing strategies that involve financial risk to insurers can reduce budgeted health expenditures. However, resource substitution may occur and negate apparent savings in budgeted expenditures. These substitutions may be important for individuals with disabling illnesses. The distribution of societal costs for adults with mental illnesses enrolled in plans that differ in their financial risk is examined to evaluate the degree to which risk-based financing strategies result in net savings or in the differential distribution of costs across public or private payers. METHOD: Six hundred twenty-eight adults with severe mental illnesses enrolled in three Medicaid plans that differ in financial risk arrangements were followed for 1 year to determine the distribution of resource use across Medicaid and other payers. Self-reported service use was obtained through interviews. Cost data were derived from self-reported expenditure, administrative, or agency data. Statistical procedures were used to control for preexisting group differences. RESULTS: Managed care was associated with a tendency toward reduced overall costs to Medicaid. However, private expenditures for managed care enrollees offset decreased Medicaid expenditures, resulting in no net difference in societal costs associated with managed care. CONCLUSIONS: Understanding the distribution of societal costs is essential in evaluating health care financing strategies. For adults with mental illnesses, efforts to manage Medicaid expenditures may result in substituting individual and family resources for Medicaid services. Government must focus on the distribution of societal costs since risk-based financing strategies may redistribute costs across the fragmented human services sector and result in unintended system inefficiencies.

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.

Examination of the effects of financial risk on the formal treatment costs for a Medicaid population with psychiatric disabilities.

OBJECTIVES: We examined the effects of differing financial risk arrangements for mental health, physical health, and pharmacy services on the overall costs of these services with particular attention to cost containment and cost shifting. METHODS: Comprehensive service utilization information was obtained from a sample of 458 adults with severe mental illnesses during a 12-month period. Rate information was used to calculate costs for health, mental health and pharmacy. A 2-part model was employed to test for differences among financial risk conditions. RESULTS: Total treatment costs, both those financed by Medicaid and those paid by other sources, were lower in plans that had a broader array of services for which they were at risk. Pharmacy costs were principally responsible for these differences. CONCLUSIONS: Treatment costs for adults with severe mental illnesses can be contained by placing providers at financial risk. However, risk arrangements may also increase treatment costs borne by other payers including charity services and self-pay. Evaluating the impact of at-risk financing mechanisms from a public health perspective requires assessing cost shifting, particularly for pharmaceuticals.

Assessment of Medicaid managed behavioral health care for persons with serious mental illness.

OBJECTIVES: This five-site study compared Medicaid managed behavioral health programs and fee-for-service programs on use and quality of services, satisfaction, and symptoms and functioning of adults with serious mental illness. METHODS: Adults with serious mental illness in managed care programs (N=958) and fee-for-service programs (N=1,011) in five states were interviewed after the implementation of managed care and six months later. After a multiple regression to standardize the groups for case mix differences, a meta-analysis using a random-effects model was conducted, and bioequivalence methods were used to determine whether differences were significant for clinical or policy purposes. RESULTS: A significantly smaller proportion of the managed care group received inpatient care (5.7 percent compared with 11.5 percent). The managed care group received significantly more hours of primary care (4.9 compared with 4.5 hours) and was significantly less healthy. However, none of these differences exceed the bioequivalence criterion of 5 percent. Managed care and fee for service were "not different but not equivalent" on 20 of 34 dependent variables. Cochrane's Q statistic, which measured intersite consistency, was significant for 20 variables. CONCLUSIONS: Managed care and fee-for-service Medicaid programs did not differ on most measures; however, a lack of sufficient power was evident for many measures. Full endorsement of managed care for vulnerable populations will require further research that assumes low penetration rates and intersite variability.

Effects of antipsychotic medication on psychiatric service utilization and cost.

BACKGROUND: Based on randomized clinical trials, consensus has been emerging that the first line of treatment for individuals with psychotic disorders should be the newer atypical or second generation antipsychotic medications rather than the older neuroleptics. Given that acquisition costs of atypical antipsychotics are generally higher than typical antipsychotics, uncertainty exists whether the newer atypicals are cost effective alternatives when used in ordinary practice settings. AIMS OF THE STUDY: The introduction of newer atypical antipsychotic agents has prompted evaluation of their overall effectiveness in reducing health care costs given their higher acquisition costs. This paper focuses on the effects of differing classes of atypical versus typical antipsychotic medications on psychiatric service utilization and cost for persons with serious mental illness treated in usual practice settings. METHODS: Descriptive statistics are used to compare patient characteristics, service rates and costs across psychotropic medication groups. Prediction equations employing ordinary least squares regression models are used to explain variation in cost due to pharmacy group membership controlling for demographics, clinical diagnoses and symptoms. Subjects were 338 Medicaid clients with serious mental illness from Florida, Pennsylvania and Oregon treated in ordinary clinical settings. Resource utilization and costs were operationalized using administrative databases to measure consumption of treatment services and pharmaceuticals for a six month period. RESULTS: Inpatient service use was significantly higher for individuals on atypical only and combination atypical/typical medications compared to those on typical medications only, whereas outpatient use was highest for those on typicals. Furthermore, six-month costs for both pharmacy and psychiatric services were significantly greater for persons in the atypical only (USD 6528) and combination typical/atypical groups (USD 6589) compared to those on typicals only (USD 3463). There were still significantly higher costs associated with atypical only and the combination typical/atypical users after multivariate controls were used. DISCUSSION: This study showed that Medicaid clients in community settings using atypical only and typical/atypical combination medications had the highest costs both in pharmacy and service use when compared to those on typical only medications. However, this study design does not allow us to ascribe a causal relationship between medication group and service costs. Given that olanzapine was the most recent medication in the compendium of available drugs at the time of this study, it is possible that those in the olanzapine only group were failing on other drugs. Caution must be used in drawing policy implications regarding cost effectiveness of newer medications since individuals who are getting the newer atypical or combination medications in community mental health center settings may be unstable on the older medications. IMPLICATIONS FOR FUTURE RESEARCH: A longer follow-up period is needed to determine if the cohort remaining on current atypical medications stabilize over time while those taking the newest drug on the market become the most costly population.

Consumer preference programs for individuals who are homeless and have psychiatric disabilities: a drop-in center and a supported housing program.

We illustrate Fairweather's approach to Experimental Social Innovation and Dissemination with two experimental studies of programs to reduce homelessness for 168 and 225 people with mental illness and often substance abuse. Literally homeless participants were randomly assigned to programs that emphasized consumer choice or to the usual continuum of care, in which housing and services are contingent on sobriety and progress in treatment. A drop-in center that eliminated barriers to access to services was more successful than control programs in reducing homelessness, but after 24 months only 38% of participants had moved to community housing. A subsequent apartment program, in which individuals in the experimental condition moved to subsidized apartments directly from the street, with services under their control, had 79% in stable housing (compared to 27% in the control group) at the end of 6 months. Groups in this study did not differ on substance abuse or psychosocial outcomes.

The effect of financial risk arrangements on service access and satisfaction among medicaid beneficiaries.

OBJECTIVE: The relationship between financial risk arrangements, access to services, and consumer satisfaction with services was assessed in a sample of Medicaid beneficiaries who were enrolled under three different financial risk arrangements for health care and mental health care. METHODS: A survey was mailed to a stratified random sample of 9,449 recipients of Supplemental Security Income. Respondents reported their health and mental health service needs, service use, and satisfaction with services. Access was measured in terms of service needs that were met. RESULTS: Access to services was related to the type of risk arrangement. Respondents who were enrolled in plans that assumed the risk for the cost of services had poorer access to services than respondents who were enrolled in plans that did not assume the risk for the cost of these services. Satisfaction with medical services was negatively related to the plan's assuming the risk for medical expenditures. CONCLUSIONS: Financial risk arrangements may have important implications for service use patterns among persons who have disabilities. Health and mental health policy makers should carefully consider risk arrangements when designing health plans for vulnerable populations.