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Managed care and the quality of substance abuse treatment.
J Ment Health Policy Econ. 2002 Dec; 5(4):163-74.JM

Abstract

BACKGROUND

In the US, the spiraling costs of substance abuse and mental health treatment caused many state Medicaid agencies to adopt managed behavioral health care (MBHC) plans during the 1990s. Although research suggests that these plans have successfully reduced public sector spending, their impact on the quality of substance abuse treatment has not been established.

AIMS OF THE STUDY

The Massachusetts Medicaid program started a risk-sharing contract with MHMA, a private, for-profit specialty managed behavioral health care (MBHC) carve-out vendor on July 1, 1992. This paper evaluates the carve-out s impact on spending per inpatient episode and three proxy measures of quality: (i) access to inpatient treatment (ii) 30-day re-admissions and (iii) continuity of care.

METHODS

Medicaid claims for inpatient treatment were collapsed into episodes. Clients were tracked across the five-year period and an interrupted time series design was used to compare the three quality outcomes and spending in the year prior to (FY1992) and the four years during MHMA (FY1993-FY1996). Logistic and linear regression models were used to control for race, disability status, age, gender and primary diagnosis.

RESULTS

Despite a 99% reduction in the use of hospital-based settings, access to 24-hour services overall increased by 38%, largely due to an expansion in the use of freestanding detoxification and acute residential services. Continuity improved by 73%. Nevertheless, rates of 7-day (58%) and 30-day (24%) readmission increased significantly, even after controlling for increases in disability status. Per episode spending decreased by 76% ($2,773), characterized by a dramatic spending reduction in FY1993 that was maintained but not augmented in subsequent years.

DISCUSSION

The carve-out had mixed effects on the quality of substance abuse treatment. While one of the three measures (readmission rates) deteriorated, two improved (access and continuity).

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

Rapid re-admissions were strongly associated with shorter lengths of stay, suggesting that strengthening discharge planning may preserve the benefits of MBHC while avoiding its risks.

IMPLICATIONS FOR HEALTH POLICIES

Since reductions in Medicaid spending were impressive but finite, MBHC may not be the permanent solution to inflation in behavioral health care. MBHC firms should implement quality-monitoring programs to ensure that aggressive utilization management strategies do not compromise quality of care.

IMPLICATIONS FOR FURTHER RESEARCH

The impact of managed behavioral health care should ideally be evaluated in randomized controlled studies. In addition, research is needed to establish that the quality measures employed in this evaluation - improved access, enhanced continuity and fewer rapid re-admissions actually correspond to reductions in drug or alcohol use and other favorable outcomes obtained through client self-report or urinalysis.

Authors+Show Affiliations

Schneider Institute for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02454-9110, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Evaluation Study
Journal Article

Language

eng

PubMed ID

14578550

Citation

Shepard, Donald S., et al. "Managed Care and the Quality of Substance Abuse Treatment." The Journal of Mental Health Policy and Economics, vol. 5, no. 4, 2002, pp. 163-74.
Shepard DS, Daley M, Ritter GA, et al. Managed care and the quality of substance abuse treatment. J Ment Health Policy Econ. 2002;5(4):163-74.
Shepard, D. S., Daley, M., Ritter, G. A., Hodgkin, D., & Beinecke, R. H. (2002). Managed care and the quality of substance abuse treatment. The Journal of Mental Health Policy and Economics, 5(4), 163-74.
Shepard DS, et al. Managed Care and the Quality of Substance Abuse Treatment. J Ment Health Policy Econ. 2002;5(4):163-74. PubMed PMID: 14578550.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Managed care and the quality of substance abuse treatment. AU - Shepard,Donald S, AU - Daley,Marilyn, AU - Ritter,Grant A, AU - Hodgkin,Dominic, AU - Beinecke,Richard H, PY - 2002/09/26/received PY - 2003/03/06/accepted PY - 2003/10/28/pubmed PY - 2004/2/20/medline PY - 2003/10/28/entrez SP - 163 EP - 74 JF - The journal of mental health policy and economics JO - J Ment Health Policy Econ VL - 5 IS - 4 N2 - BACKGROUND: In the US, the spiraling costs of substance abuse and mental health treatment caused many state Medicaid agencies to adopt managed behavioral health care (MBHC) plans during the 1990s. Although research suggests that these plans have successfully reduced public sector spending, their impact on the quality of substance abuse treatment has not been established. AIMS OF THE STUDY: The Massachusetts Medicaid program started a risk-sharing contract with MHMA, a private, for-profit specialty managed behavioral health care (MBHC) carve-out vendor on July 1, 1992. This paper evaluates the carve-out s impact on spending per inpatient episode and three proxy measures of quality: (i) access to inpatient treatment (ii) 30-day re-admissions and (iii) continuity of care. METHODS: Medicaid claims for inpatient treatment were collapsed into episodes. Clients were tracked across the five-year period and an interrupted time series design was used to compare the three quality outcomes and spending in the year prior to (FY1992) and the four years during MHMA (FY1993-FY1996). Logistic and linear regression models were used to control for race, disability status, age, gender and primary diagnosis. RESULTS: Despite a 99% reduction in the use of hospital-based settings, access to 24-hour services overall increased by 38%, largely due to an expansion in the use of freestanding detoxification and acute residential services. Continuity improved by 73%. Nevertheless, rates of 7-day (58%) and 30-day (24%) readmission increased significantly, even after controlling for increases in disability status. Per episode spending decreased by 76% ($2,773), characterized by a dramatic spending reduction in FY1993 that was maintained but not augmented in subsequent years. DISCUSSION: The carve-out had mixed effects on the quality of substance abuse treatment. While one of the three measures (readmission rates) deteriorated, two improved (access and continuity). IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Rapid re-admissions were strongly associated with shorter lengths of stay, suggesting that strengthening discharge planning may preserve the benefits of MBHC while avoiding its risks. IMPLICATIONS FOR HEALTH POLICIES: Since reductions in Medicaid spending were impressive but finite, MBHC may not be the permanent solution to inflation in behavioral health care. MBHC firms should implement quality-monitoring programs to ensure that aggressive utilization management strategies do not compromise quality of care. IMPLICATIONS FOR FURTHER RESEARCH: The impact of managed behavioral health care should ideally be evaluated in randomized controlled studies. In addition, research is needed to establish that the quality measures employed in this evaluation - improved access, enhanced continuity and fewer rapid re-admissions actually correspond to reductions in drug or alcohol use and other favorable outcomes obtained through client self-report or urinalysis. SN - 1091-4358 UR - https://www.unboundmedicine.com/medline/citation/14578550/Managed_care_and_the_quality_of_substance_abuse_treatment_ L2 - http://www.icmpe.net/fulltext.php?volume=5&page=163&year=2002&num=4&name=Shepard DS DB - PRIME DP - Unbound Medicine ER -