Financial Capability: Clinicians' Assessment of Beneficiaries With Dual Diagnoses.

OBJECTIVE: Adults with mental health disorders whose ability to work is sufficiently impeded are entitled to financial supports from the Social Security Administration. Beneficiaries determined to be incapable of managing these funds are supposed to be assigned a representative payee to assist beneficiaries in meeting their needs. However, patterns of payee assignment suggest that payee assignment is impacted by factors other than those the Social Security Administration instructs clinicians to consider. In this study, we tested the association between clinicians' judgments of their clients' financial capability and hypothesized predictors (demographic characteristics, psychiatric diagnosis, recent alcohol and other substance use, self-rated money mismanagement, recent homelessness, and provider characteristics). We posited that predictors might act indirectly on capability judgment via their impact on beneficiaries' money management. METHODS: Altogether, 261 people receiving intensive mental health care who did not have payees or fiduciaries were enrolled after providing written informed consent. These beneficiaries completed in-person assessment interviews, reporting demographic characteristics, treatment history, substance use, and homelessness. Mental health clinicians identified by the beneficiaries were enrolled in the study and asked to judge their clients' financial capability with standard Social Security instructions for determining capability. Bivariate associations between hypothesized predictors and clinicians' determinations of incapability were tested. In multivariate probit regression models, incapability determination was modeled as a function of all beneficiary and clinician characteristics that had significant bivariate associations with the outcome. RESULTS: Providers identified 24% of their clients as financially incapable. Determinations of financial incapability were unrelated to any beneficiary or provider demographic characteristics but were positively associated with money mismanagement, homelessness, and having a psychotic disorder. Alcohol use and other substance use were only significantly associated with capability determinations indirectly through their effects on money mismanagement. CONCLUSIONS: Providers' judgments of beneficiaries' capability to manage their funds were associated with factors that were consistent with Social Security Administration guidelines and were, importantly, not associated with personal characteristics. This finding suggests that guidelines can be fairly applied by clinicians and that reported inconsistencies in payee assignment are accounted for by other factors. The Social Security Administration is currently considering other approaches to standardize capability determinations.

Factors associated with high levels of spending for younger dually eligible beneficiaries with mental disorders.

The Affordable Care Act focused attention on how conflicting rules and payment arrangements in Medicare and Medicaid can produce high costs and fragmented care for people who are dually eligible for the two programs. Nearly half of such dual eligibles have severe and persistent mental disorders. Using Medicare data for the period 2006-09, we examined factors that were associated with high levels of spending for dual eligibles younger than sixty-five with a mental disorder. We found that these beneficiaries were nearly twice (1.86 times) as expensive as young dual eligibles who did not have a mental disorder. We identified functional limitations, multiple chronic conditions, and substance use disorders as being associated with high levels of spending in this subpopulation. We conclude that case management that coordinated medical, mental health, and substance use treatment along with psychosocial rehabilitation services could yield savings, primarily to the Medicare program. Because only Medicaid pays for case management and psychosocial rehabilitation services, Medicaid spending may need to rise if overall savings are to be realized.

Criminal justice and behavioral health care costs of mental health court participants: a six-year study.

OBJECTIVE: This study examined whether there were differences in costs for mental health court (MHC) participants and a matched comparison group for three years after a target arrest. METHODS: Data from the MacArthur Mental Health Court Study, the first multisite study of MHCs, were used to compare behavioral health treatment and criminal justice costs for MHC participants and a matched group (using coarsened exact matching) of jail detainees who were not enrolled in an MHC but who received jail-based psychiatric services in the same cities. Cost data for three years before and after a target arrest were calculated separately for each year and for each participant at three sites of the multisite study-296 MHC participants and 386 matched jail detainees. High-cost MHC participants were identified. RESULTS: Total annual costs for MHC participants averaged $4,000 more for all three follow-up years. The additional costs resulted from treatment costs, which were not offset by criminal justice cost savings. The highest-cost MHC participants were those with diagnoses of co-occurring substance use disorders and those who had more arrest incarceration days before their target arrest. Separate analyses determined that the higher average costs were not the result of outlier cases. CONCLUSIONS: Participation in an MHC may not result in total cost savings in the three years after enrollment. To become more efficient and to serve participants with the greatest needs, MHCs need to more effectively define the target group for intervention.

Does assigning a representative payee reduce substance abuse?

BACKGROUND: Approximately 700,000 Social Security beneficiaries in the U.S. with psychiatric disabilities have been assigned a representative payee to manage their funds but it is unclear how those judged to need a payee differ from others and whether payee assignment improves clinical outcomes, especially substance abuse. METHODS: Participants in this observational 12-month cohort study (n=1457) received SSI or SSDI and had serious mental illness. They were subsequently enrolled at eighteen community-based sites that provided Assertive Community Treatment. Social Security administrative records were used to determine whether a payee had been assigned. RESULTS: At baseline, participants who were assigned a payee were more likely to have schizophrenia and had more severe clinician-rated drug and alcohol use than those not assigned a payee. In GEE models that adjusted for these and other potentially confounding covariates, participants assigned a payee between 4 and 12 months after program entry subsequently used significantly more psychiatric services than participants not assigned payees but showed no greater reduction in substance use. CONCLUSIONS: Although substance use is associated with being assigned a payee, substance use does not decline substantially following payee assignment. Participants assigned payees made greater subsequent use of psychiatric services, suggesting the potential for benefit from payee assignment.

Outcomes and costs of matching the intensity of dual-diagnosis treatment to patients' symptom severity.

This study evaluated a patient-treatment matching strategy intended to improve the effectiveness and cost-effectiveness of acute treatment for dual-diagnosis patients. Matching variables were the severity of the patient's disorders and the program's service intensity. Patients (N = 230) with dual substance use and psychiatric disorders received low or high service-intensity acute care in 1 of 14 residential programs and were followed up for 1 year (80%) using the Addiction Severity Index. Patients' health care utilization was assessed from charts, Department of Veterans Affairs (VA) databases, and health care diaries; costs were assigned using methods established by the VA Health Economics Resource Center. High-severity patients treated in high-intensity programs had better alcohol, drug, and psychiatric outcomes at follow-up, as well as higher health care utilization and costs during the year between intake and follow-up than did those in low-intensity programs. For moderate-severity patients, high service intensity improved the effectiveness of treatment in only a single domain (drug abuse) and increased costs of the index stay but did not increase health care costs accumulated over the study year. Moderate-severity patients generally had similar outcomes and health care costs whether they were matched to low-intensity treatment or not. For high-severity patients, matching to higher service intensity improved the effectiveness of treatment as well as increased health care costs. Research is needed to establish standards by which to judge whether the added benefits of high-intensity acute care justify the extra costs.

Psychiatric service utilization and cost for persons with schizophrenia in a Medicaid managed care program.

A pre-post study design was used to look at changes in behavioral health care services and costs for Medicaid-eligible individuals with schizophrenia in a managed care (MC) carve-out compared to a fee-for-service (FFS) program in Pennsylvania between 1995 and 1998. Statistically significant reductions of 59% were found in hospital expenditures in the MC program compared to 18.3% in the FFS program. The decline in hospital costs was due to dramatic fee reductions in the MC site. No significant differences in overall ambulatory utilization were found in either program; however, ambulatory expenditures rose 57% in the MC program versus a decline of 11% in fee for service. The ambulatory cost increase resulted from a cost shift between county block grant funds, and Medicaid funds, with no additional revenues provided to outpatient providers. Study implications are that cost reductions from MC are mainly due to reducing utilization and payments to hospitals, similar to the findings for private sector programs.

A dual diagnosis demonstration project: treatment outcomes and cost analysis.

This article presents findings from an outpatient dual diagnosis demonstration project that investigated whether integrated treatment services for severely and persistently ill patients with co-occurring mental health and substance abuse disorders could result in improved outcomes and reduction of criminal justice and health care costs. Integrated treatment was defined as a simultaneous focus on both disorders through the provision of psychosocial rehabilitation, psychotherapeutic and psychopharmacologic treatment, and substance abuse recovery and relapse prevention by cross-trained staff. One hundred twenty six (126) patients with multiple DSM-IV Axis I and Axis II disorders were assessed on a variety of mental health, substance abuse, and quality of life measures at baseline and at six-month intervals up to three years post entry into treatment. Criminal justice and health care costs obtained from state and local databases were compared two years before and two years after initiation of treatment to determine cost differences. The study found statistically significant improvements in psychiatric symptoms, substance abuse, and quality of life outcomes. There were also decreases in criminal justice and acute and sub-acute mental health and alcohol and other drug (AOD) costs and increases in outpatient mental health and physical health care costs.

Substance abuse and the need for money management assistance among psychiatric inpatients.

Patients who mismanage their funds may benefit from financial advice, case management or the involuntary assignment of a payee who restricts direct access to funds. Data from a survey of psychiatric inpatients at four VA hospitals (N = 236) was used to evaluate the relationship between substance abuse and clinician-rated need for money management assistance. Multivariate analytic techniques were used to control for sociodemographic factors and psychopathology. Alcohol and drug use severity both were modestly associated with need for assistance. The effect of substance use severity was greater in patients who were also diagnosed with a major mental illness. Clinicians indicated that 27 patients (11% of the sample) required an involuntary payee and 21 of the 27 (78%) had a Substance Abuse diagnosis. Only drug use severity was significantly associated with need for a payee. These data describe a substantial unmet need for money management assistance in psychiatric inpatients, particularly among those with substance abuse disorders. There is a need to examine the process by which the Social Security and Veterans Benefits Administrations assign payees to determine whether patients with co-morbid substance abuse are not being assigned a payee in spite of their discernible need for one.

The co-occurrence of psychiatric and substance use diagnoses in adolescents in different service systems: frequency, recognition, cost, and outcomes.

The frequency, severity, recognition, cost, and outcomes of adolescent substance use comorbidity were analyzed in the Fort Bragg Demonstration Project. Comorbidity was defined as the co-occurrence of substance use disorder (SUD) with other psychiatric diagnosis. The sample consisted of 428 adolescent clients whose providers' diagnoses were compared with research diagnoses. The project identified 59 clients (13.8%) with SUD, all with additional psychiatric diagnoses. Providers recognized only 21 of these 59 comorbid cases. The frequency and severity of comorbidity did not differ between service system samples, although recognition did. Comorbid clients had more behavior problems and more functioning impairment, and their average treatment cost ($29,057) was more than twice as high as that of noncomorbid clients ($13,067). Mental health outcomes were not influenced by type of service system, comorbid diagnosis, or treatment. Screening for and prevention of SUD are discussed as a potential cost-savings opportunity in mental health services.

Service use and costs of people with dual diagnosis in South London.

OBJECTIVE: To compare the service use and costs of individuals who have a dual diagnosis of psychosis and substance abuse with those who have a diagnosis of psychosis but no substance abuse. METHOD: Patients with psychosis were identified and a representative sample were interviewed. Six-month service use was measured and costs calculated. Regression models were developed to predict costs from background characteristics and dual diagnosis status. RESULTS: A greater proportion of the patients with dual diagnosis used community psychiatric nurses, in-patient care and the emergency clinic. The regression analysis revealed that dual diagnosis patients had significantly higher 'core' psychiatric service costs (a difference of pound sterling 1362) and non-accommodation service costs (pound sterling 1360) than non-dual-diagnosis patients. The difference when all services were analysed was pound sterling 1046, but this was not statistically significant. CONCLUSION: Specific interventions for dual diagnosis patients should be introduced and assessed in terms of individual outcomes, service use and costs.

Cost-effectiveness of mental health services for persons with a dual diagnosis: a literature review and the CCMHCP. The Cost-Effectiveness of Community Mental Health Care for Single and Dually Diagnosed Project.

People suffering from comorbid mental illness and substance abuse disorders (the dually diagnosed) are thought to constitute large portions of clients treated as outpatients by public-sector community-based mental health providers. These providers dispense units of ambulatory mental health services and treatments incrementally to maintain clients in the community and out of psychiatric hospitals. Community maintenance is one step, albeit critical, toward quitting drugs and eventual abstinence. Thus, there is a need for information that compares the effectiveness and cost of such services on dually diagnosed clients to identify appropriate low-cost high-yield treatment and service options and packages. This article provides a review of the literature on the effectiveness of ambulatory mental health services and recent emergent reports of cost-effectiveness of programs for the dually diagnosed, paying special attention to the gray areas and gaps. This article also describes a new project; an inexpensive add-on to an existing community mental health center. The project will be examining over 4 years of data to compare influence and cost of different ambulatory mental health services and treatments delivered to a matched pair group of clients with dual disorders and those with only mental illness. The intention of this project is not only to address gray areas and gaps in the literature, but also to inform a more rational deployment of mental health services.

Innovations in integrated dual diagnosis treatment in public managed care: the Choate dual diagnosis case rate program.

This article describes the implementation and preliminary evaluation of a dual diagnosis case rate program developed as a collaborative experiment between a public managed Medicaid organization (MHMA) and a specialized integrated dual diagnosis provider (Choate) with a vertically integrated, managed-care oriented system of care. The case rate program applied to dually-diagnosed inpatient referrals for a period of 65 days. On admission, 68% of the patients had little insight, motivation and compliance regarding addiction or psychiatric management. Nonetheless, 56% maintained sobriety for 65 days, and 49% of these were still sober at 95-day follow up.

Legal system involvement and costs for persons in treatment for severe mental illness and substance use disorders.

OBJECTIVE: Persons with co-occurring severe mental illness and substance use disorders were followed for three years to better understand how they are involved with the legal system and to identify factors associated with different kinds of involvement. METHODS: Data came from a three-year study of 203 persons enrolled in specialized treatment for dual disorders. Cost and utilization data were collected from multiple data sources, including police, sheriffs and deputies, officers of the court, public defenders, prosecutors, private attorneys, local and county jails, state prisons, and paid legal guardians. RESULTS: Over three years 169 participants (83 percent) had contact with the legal system, and 90 (44 percent) were arrested at least once. Participants were four times more likely to have encounters with the legal system that did not result in arrest than they were to be arrested. Costs associated with nonarrest encounters were significantly less than costs associated with arrests. Mean costs per person associated with an arrest were $2,295, and mean costs associated with a nonarrest encounter were $385. Combined three-year costs averaged $2,680 per person. Arrests and incarcerations declined over time. Continued substance use and unstable housing were associated with a greater likelihood of arrest. Poor treatment engagement was associated with multiple arrests. Men were more likely to be arrested, and women were more likely to be the victims of crime. CONCLUSIONS: Effective treatment of substance use among persons with mental illness appears to reduce arrests and incarcerations but not the frequency of nonarrest encounters. Stable housing may also reduce the likelihood and number of arrests.

Breaking the cycle of dependency: dual diagnosis and AFDC families.

This paper proposes that a comprehensive, long-term program with a case-management focus will produce better outcomes and be more cost-effective than the current approach to managing the illnesses of women on Temporary Assistance for Needy Families (or TANF, formerly known as AFDC) who are afflicted with both drug dependency and mental illness, i.e. a dual diagnosis. It is proposed that this comprehensive approach would diminish the generational cycle of substance abuse, dysfunction (including violence), and dependence on public support, which is too often the pattern in single-parent homes where the mother has been dually diagnosed. For our purposes, dual diagnosis is defined as any mental health diagnosis using the DSM-IV criteria coexisting with a diagnosis of substance abuse, whether licit or illicit. Current drug policy, particularly as it applies to those with a dual diagnosis, has an emphasis on criminal justice system solutions. It is extremely expensive (incarceration alone is variously estimated as costing $25,000 to $45,000 per year per person), and does little to treat, prevent, or consequently, reduce the problem. The model design discussed in this article provides for comprehensive treatment and support services to women with a dual diagnosis receiving TANF. Its goal is to help break the family cycle of system dependency. The article hypothesizes that if a well-designed program evaluation is implemented, it will demonstrate savings in reduced health care, criminal justice, and social service costs.

Analysis of three interventions for substance abuse treatment of severely mentally ill people.

Severely mentally ill people with co-occurring substance abuse disorders are difficult to treat and the course of their psychiatric treatment is worsened by substance abuse. Despite increased attention to the problem, few studies of specialized treatment are reported in the literature and most lack detail about the specialized interventions employed. Qualitative data, gathered as part of a larger study of the cost-effectiveness of three substance abuse interventions for severely mentally ill people, are presented which describe the interventions, their implementation in four community mental health centers over 18 months of the study, and their relationship to the quantitative outcomes. Illustrated is the difficulty of implementing innovative programs and the need for vigilance concerning program fidelity.

Private sector coverage of people with dual diagnoses.

In general, people with dual diagnoses account for a significant proportion of both the mental health and substance abuse populations. Most published information on dual diagnosis comes from research on selected treatment programs that are largely funded from public sources. This analysis uses private health insurance claims and eligibility files for 1989 to 1991 for three large firms to identify individuals with both substance abuse and mental health claims and to examine their characteristics, charges, and utilization. More than half of people with dual diagnoses incurred significant charges over three years in both mental health and substance abuse. These individuals with high mental health charges were more likely to be male than were patients with mental health claims alone; they were less likely to be male than were patients with claims for substance abuse and no mental health services. They were also significantly younger than were patients with substance abuse or mental health utilization only for two of the firms. The average charges for people with dual diagnoses were higher than those for patients with substance abuse or mental health claims only.

Toward cost-effective care for persons with dual diagnoses.

Implementing services that control costs and improve client functioning for persons with both severe psychiatric and substance disorders is paramount in a managed care environment. In this clinical trial, standard mental health care augmented by the behavioral skills intervention was more effective than two other approaches (case management and modified 12-step recovery) in interventions with persons with dual diagnoses across indicators of psychosocial adjustment, psychiatric and substance abuse symptoms, and mental health service costs. These findings reinforce the need to address mental health and substance disorders concomitantly; to provide skill-building interventions as the primary ingredient of active treatment to address various instrumental, coping, and social skill deficits that clients with dual diagnoses have; and to monitor the effectiveness of the services and client progress every six months on multiple adjustment and symptomatology dimensions.