Differential Access to Services for Co Occurring Mental Health and Substance Abuse Disorders Across Managed Care and Fee for Service Systems

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Differential Access to Services for Co Occurring Mental Health and Substance Abuse Disorders Across Managed Care and Fee for Service Systems Powered By Docstoc
					Differential Access to Services for Co-
occurring Mental Health and Substance
Abuse Disorders across Managed Care
and Fee for Service Systems: A Multi-
State Study


Roy M. Gabriel, Ph.D.1 Bentson H. McFarland, M.D.2
Brigid G. Zani, M.S.2 Lynn E. McCamant, M.S.2

1   RMC Research Corporation; Portland, Oregon
2   Oregon Health & Science University; Portland, Oregon




     2006 Academy Health Annual Research
       Meeting; June 25-27; Seattle, WA
Co-Occurring Mental Health and
Substance Abuse Disorders

 SAMHSA Report to Congress, 2002:
  COD the ―expectation‖ not the
  ―exception‖
 SA Tx programs typically report 50%-
  75% of clients w/MH disorder
 MH clients also have elevated rates of
  substance abuse


         2006 Academy Health Annual Research
           Meeting; June 25-27; Seattle, WA
If Treated in Only One System
or the Other

 Worsening psychiatric symptoms
 Longer treatment stays
 More likely to be hospitalized
 Disproportionate representation in
  criminal justice system, homeless



         2006 Academy Health Annual Research
           Meeting; June 25-27; Seattle, WA
Medicaid Managed Care

 Majority of SA and MH Tx now publicly
  funded
 Medicaid behavioral health programs
  shifting away from fee for service (FFS)
  and toward managed care (MC)
 SAMHSA studies examining impact of
  shift to MC on SA and MH services
  separately

         2006 Academy Health Annual Research
           Meeting; June 25-27; Seattle, WA
Barriers to COD Services

 Different need, referral criteria in SA and
  MH service systems
 Separate reporting and reimbursement
  systems
 Duplication of needed documentation


      Disincentive to Identify and Serve?


         2006 Academy Health Annual Research
           Meeting; June 25-27; Seattle, WA
SAMHSA Studies of Impact of Managed
Care on Services to Vulnerable
Populations, 1996–2000
 Adults w/Serious Mental Illness (SMI)
     SMI clients in 5 state systems (N = 2,318)
     Oregon, Pennsylvania, Virginia, Florida,
      Hawaii
 Adults in Substance Abuse Tx (SA)
     SA clients in 5 state systems (N = 2,424)
     Oregon, Washington, Massachusetts,
      Pennsylvania, New York


           2006 Academy Health Annual Research
             Meeting; June 25-27; Seattle, WA
Existing Data Sets from
SAMHSA Studies
 Quasi-experimental comparison of adults
  receiving services in MC or FFS systems
 Structured interviews at treatment entry
  and 6 months later
 Included standardized measures
     SMI population: BSI, SF-12, ASI
     SA population: ASI, SF-12



          2006 Academy Health Annual Research
            Meeting; June 25-27; Seattle, WA
Research Questions

 For SMI clients
    What proportion of SMI clients received SA
     services during study period?
    What client characteristics were associated
       w/receipt of SA services?
 For SA clients
      What proportion of SA clients received MH
       services during study period?
      What client characteristics were associated
       w/receipt of MH services?
            2006 Academy Health Annual Research
              Meeting; June 25-27; Seattle, WA
Analysis Framework: Andersen
Behavioral Model of Access to
Health Care

 Predisposing Characteristics


 Enabling Characteristics


 Need Characteristics




         2006 Academy Health Annual Research
           Meeting; June 25-27; Seattle, WA
Study Variables
           Predisposing              Enabling            Need

                 Age              Ever had SA Tx    ASI Alcohol Use

SAMHSA        Gender             Ever had MH Tx      ASI Drug Use
SA Tx     Race/Ethnicity          Referral Source   ASI Psychiatric
Study       Educ Level               MC or FFS       Activity Limits
             Employed                                    SF-12
           Marital Status


                 Age              Ever had SA Tx    ASI Alcohol Use

SAMHSA        Gender             SA Tx past 3 mo     ASI Drug Use
SMI Tx    Race/Ethnicity             MC or FFS        BSI Global
Study       Educ Level                                   SF-12
             Employed
           Marital Status
         2006 Academy Health Annual Research
           Meeting; June 25-27; Seattle, WA
Descriptive/Comparative
Results: SMI Clients
 Predominantly female (58%), non-White (55%),
  unemployed (86%), ave. 43 yrs old
 More likely to receive SA Tx in FFS (15%) than
  MC (9%) (p < .001)
 MC sample reported more severe drug
  problems, MH symptoms, and poorer mental
  and physical health than FFS
 MC/FFS Comparisons varied significantly
  across states


          2006 Academy Health Annual Research
            Meeting; June 25-27; Seattle, WA
Descriptive/Comparative
Results: SA Clients
 Predominantly male (60%), non-White (58%),
    unemployed (86%), ave. 38 yrs old
   More likely to receive MH Tx in MC (24%) than
    FFS (13%) (p < .001)
   MC sample reported more severe MH problems
    and limitations in daily activities due to
    emotional problems.
   FFS sample reported more severe drug
    problems.
   MC/FFS comparisons varied significantly
    across states
           2006 Academy Health Annual Research
             Meeting; June 25-27; Seattle, WA
 Odds Ratios: Predicting SA Tx
 Access among SMI Clients
        Mental Health (SF-12)                 1.01

       Physical Health (SF-12)                1.01

Symptom Severity (BSI Global)                 1.01
          Drug Problem (ASI)                                                     7.80*

       Alcohol Problems (ASI)                                 1.60



               In FFS System                           1.35
                                                       *
       Ever had SA Treament                                                      3.76***



         Living Independently                1.02

                 Ever Married                1.01

                    Employed                     1.28
                                                                         * p < .05
               HS+ Education                    1.20                   ** p < .01
                                               1.13
                                                                     *** p < .001
        Race/Ethnicity (White)

             Gender (Female)                    1.16

               Age (Younger)                  1.02**


                       2006 Academy Health Annual Research
                         Meeting; June 25-27; Seattle, WA
Odds Ratios: Predicting MH Tx
Access among SA Clients
     Mental Health (SF-12)                 1.01
   Physical Health (SF-12)                 1.01
Limited Activity/Emotional                 1.07
Psychiatric Problems (ASI)                                                             3.10***
       Drug Problem (ASI)                             1.49

   Alcohol Problems (ASI)                  1.02


           In M.C. System                        1.24*
   Ever had MH Treatment                                             2.18***
   Ever had SA Treatment                  1.01


            Not Homeless                                   1.68***
             Ever Married                  1.01
                                                   1.36                        * p < .05
            Not Employed
                                                                             ** p < .01
           HS+ Education                   1.06                            *** p < .001
    Race/Ethnicity (White)                         1.32*
         Gender (Female)                                 1.54***

              Age (Older)                  1.02*


                      2006 Academy Health Annual Research
                        Meeting; June 25-27; Seattle, WA
Conclusions

 MC had differential impact on SA and MH
  services—Different systems
 Need factors are most predictive of concurrent
  SA or MH service access
 Several predisposing factors, even after
  controlling for need, suggestive of disparities in
  access
      Females more likely to access MH Tx
      Whites more likely to access MH Tx
 Substantial variation across states in MC/FFS
  sample comparisons—Different systems
            2006 Academy Health Annual Research
              Meeting; June 25-27; Seattle, WA
Study Limitations

 Clients not randomly assigned to
  MC/FFS conditions
 Study samples not selected as
  representative of each state’s clients
 Measures conceptually parallel, but not
  precisely the same, across SA and MH
  samples
 Concurrent SA/MH service use is self-
  reported, i.e., from client’s perspective

         2006 Academy Health Annual Research
           Meeting; June 25-27; Seattle, WA
Implications

 Broad, sweeping policy shifts (from FFS
  to MC) can have differential effects on
  Medicaid sub-populations
 Variations among state systems key in
  understanding differences in MC/FFS
  groups and in access to SA/MH
  treatment



         2006 Academy Health Annual Research
           Meeting; June 25-27; Seattle, WA
Thanks to Principal Investigators
of SAMHSA Studies
SA Population                         SMI Population

   Dr. Mary Jo Larson                       Dr. Joseph Morrissey
    NE Research Inst.                        Univ. North Carolina
   Dr. Frank McCorry                        Dr. Aileen Rothbard
    NY State OASAS                           Univ. Pennsylvania
   Dr. Thomas McLellan                      Dr. David Shern
    Tx Research Inst.                        Univ. South Florida
   Dr. Roy Gabriel                          Dr. Michael Wylie
    RMC Research Corp.                       Univ. Hawaii
                                            Dr. Bentson McFarland
                                             Oregon Health &
                                              Science Univ.


           2006 Academy Health Annual Research
             Meeting; June 25-27; Seattle, WA
Added Thanks to:

National Coordinating Center: Human Service
  Research Institute
   Dr. Virginia Mulkern
   Dr. Stephen Leff
   Mr. David Hughes


SAMHSA GPOs
   Dr. Mady Chalk, (then) CSAT
   Ms. Frances Cotter, CSAT
   Dr. Jeff Buck, CMHS

           2006 Academy Health Annual Research
             Meeting; June 25-27; Seattle, WA
Questions, Further Information



       rgabriel@rmccorp.com




      2006 Academy Health Annual Research
        Meeting; June 25-27; Seattle, WA

				
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