Exploratory analysis on payment mechanisms to Community Mental Health Centers in Chile using mixed grounded theory. / Análisis exploratorio sobre los mecanismos de pago a centros de salud mental comunitaria en Chile usando teoría fundamentada mixta.

Introduction: Research on psychiatric deinstitutionalization has neglected that reforms in this field are nested in a health system that has undergone financial reforms. This subordination could introduce incentives that are misaligned with new mental health policies. According to Chile's National Mental Health Plan, this would be the case in the Community Mental Health Centers (CMHC). The goal is to understand how the CMHCpayment mechanism is a potential incentive for community mental health. Methods: A mixed quantitative-qualitative convergent study using grounded theory. We collected administrative production data between 2010 and 2020. Following the payment mechanism theory, we interviewed 25 payers, providers, and user experts. We integrated the results through selective coding. This article presents the relevant results of mixed selective integration. Results: Seven payment mechanisms implemented heterogeneously in the country's CMHC are recognized. They respond to three schemes subject to rate limits and prospective public budget. They differ in the payment unit. They are associated with implementing the community mental health model negatively affecting users, the services provided, the human resources available, and the governance adopted. Governance, management, and payment unit conditions favoring the community mental health model are identified. Conclusions: A disjointed set of heterogeneously implemented payment schemes negatively affects the community mental health model. Formulating an explicit financing policy for mental health that is complementary to existing policies is necessary and possible.

Introducción: La investigación sobre desinstitucionalización psiquiátrica ha descuidado el hecho que las reformas en este campo se anidan en un sistema de salud que se ha sometido a reformas financieras. Esta subordinación podría introducir incentivos desalineados con las nuevas políticas de salud mental. Según el Plan Nacional de Salud Mental de Chile, este sería el caso en los centros de salud mental comunitaria. El objetivo es comprender cómo el mecanismo de pago al centro de salud mental comunitaria es un potencial incentivo para la salud mental comunitaria. Métodos: Este es un estudio mixto cuantitativo-cualitativo convergente, que utiliza la teoría fundamentada. Recolectamos datos administrativos de producción entre 2010 y 2020. Siguiendo la teoría de mecanismo de pago, entrevistamos a 25 expertos de los ámbitos pagador, proveedor y usuario. Integramos los resultados a través de la codificación selectiva. Este artículo presenta los resultados relevantes de la integración selectiva mixta. Resultados: Reconocimos siete mecanismos de pago implementados heterogéneamente en los centros de salud mental comunitaria del país. Estos, responden a tres esquemas supeditados a límites de tarifa y presupuesto público prospectivo. Se diferencian en la unidad de pago. Se asocian con la implementación del modelo de salud mental comunitaria afectando negativamente a los usuarios, los servicios provistos, los recursos humanos disponibles, la gobernanza adoptada. Identificamos condiciones de gobernanza, gestión y unidad de pago que favorecerían el modelo de salud mental comunitaria. Conclusiones: Un conjunto desarticulado de esquemas de pago implementados heterogéneamente, tiene efectos negativos para el modelo de salud mental comunitaria. Es necesario y posible formular una política de financiación explícita para la salud mental complementaria a las políticas existentes.

Cost of a community mental health service: a retrospective study on a psychosocial care center for alcohol and drug users in São Paulo.

BACKGROUND: Psychosocial care centers for alcohol and drug users (CAPS-ad) are reference services for treatment of drug users within the Brazilian National Health System. Knowledge of their total costs within the evidence-based decision-making process for public-resource allocation is essential. The aims here were to estimate the total costs of a CAPS-ad and the costs of packages of care (according to intensity of care); to ascertain the ratio between total CAPS-ad costs and the federal funding allocated; and to describe the methods for estimating unit costs for each CAPS-ad cost component. DESIGN AND SETTING: Retrospective study conducted in a public community mental health service. METHODS: This was a retrospective cost description study on a CAPS-ad located in a city in the state of São Paulo, using a public healthcare provider perspective and a top-down approach, conducted over a 180-day period from March 1 to August 30, 2015. RESULTS: The total mean monthly costs of the CAPS-ad were BRL 64,017.54. Healthcare staff accounted for 56.5% of total costs. The mean costs per capita and per month for intensive and non-intensive care packages were, respectively, BRL 668.34 and BRL 37.12. CONCLUSIONS: The federal budget allocation covered 62.1% of the CAPS-ad costs and the remaining 37.9% end up funded by the municipal government. The cost of the intensive package of care was 18 times greater than the non-intensive package. Developing criteria for using services and different packages of care based on patients' needs, and optimizing human resources according to specific actions, may improve people's mental health and avoid wasted resources.

An Economic Evaluation of Coordinated Specialty Care (CSC) Services for First-Episode Psychosis in the U.S. Public Sector.

BACKGROUND: Schizophrenia spectrum disorders exert a large and disproportionate economic impact. Early intervention services may be able to alleviate the burden of schizophrenia spectrum disorders on diagnosed individuals, caregivers, and society at large. Economic analyses of observational studies have supported investments in specialized team-based care for early psychosis; however, questions remain regarding the economic viability of first-episode services in the fragmented U.S. healthcare system. The clinic for Specialized Treatment Early in Psychosis (STEP) was established in 2006, to explicitly model a nationally-relevant U.S. public-sector early intervention service. The purpose of this study was to conduct an economic evaluation of STEP, a Coordinated Specialty Care service (CSC) based in a U.S. State-funded community mental health center, relative to usual treatment (UT). METHODS: Eligible patients were within 5 years of psychosis onset and had no more than 12 weeks of lifetime antipsychotic exposure. Participants were randomized to STEP or UT. The annual per-patient cost of the STEP intervention per se was estimated assuming a steady-state caseload of 30 patients. A cost-offset analysis was conducted to estimate the net value of STEP from a third-party payer perspective. Participant healthcare service utilization was evaluated at 6 months and over the entire 12 months post randomization. Generalized linear model multivariable regressions were used to estimate the effect of STEP on healthcare costs over time, and generate predicted mean costs, which were combined with the per-patient cost of STEP. RESULTS: The annual per-patient cost of STEP was $1,984. STEP participants were significantly less likely to have any inpatient or ED visits; among individuals who did use such services in a given period, the associated costs were significantly lower for STEP participants at month 12. We did not observe a similar effect with regard to other healthcare services. The predicted average total costs were lower for STEP than UT, indicating a net benefit for STEP of $1,029 at month 6 and $2,991 at month 12; however, the differences were not statistically significant. CONCLUSIONS: Our findings are promising with regard to the value of STEP to third-party payers.

Cost of a community mental health service: a retrospective study on a psychosocial care center for alcohol and drug users in São Paulo

ABSTRACT BACKGROUND: Psychosocial care centers for alcohol and drug users (CAPS-ad) are reference services for treatment of drug users within the Brazilian National Health System. Knowledge of their total costs within the evidence-based decision-making process for public-resource allocation is essential. The aims here were to estimate the total costs of a CAPS-ad and the costs of packages of care (according to intensity of care); to ascertain the ratio between total CAPS-ad costs and the federal funding allocated; and to describe the methods for estimating unit costs for each CAPS-ad cost component. DESIGN AND SETTING: Retrospective study conducted in a public community mental health service. METHODS: This was a retrospective cost description study on a CAPS-ad located in a city in the state of São Paulo, using a public healthcare provider perspective and a top-down approach, conducted over a 180-day period from March 1 to August 30, 2015. RESULTS: The total mean monthly costs of the CAPS-ad were BRL 64,017.54. Healthcare staff accounted for 56.5% of total costs. The mean costs per capita and per month for intensive and non-intensive care packages were, respectively, BRL 668.34 and BRL 37.12. CONCLUSIONS: The federal budget allocation covered 62.1% of the CAPS-ad costs and the remaining 37.9% end up funded by the municipal government. The cost of the intensive package of care was 18 times greater than the non-intensive package. Developing criteria for using services and different packages of care based on patients' needs, and optimizing human resources according to specific actions, may improve people's mental health and avoid wasted resources.

Community Mental Health Center Integrated Care Outcomes.

Despite the compelling logic for integrating care for people with serious mental illness, there is also need for quantitative evidence of results. This retrospective analysis used 2013-2015 data from seven community mental health centers to measure clinical processes and health outcomes for patients receiving integrated primary care (n = 18,505), as well as hospital use for the 3943 patients with hospitalizations during the study period. Bivariate and regression analyses tested associations between integrated care and preventive screening rates, hemoglobin A1c levels, and hospital use. Screening rates for body-mass index, blood pressure, smoking, and hemoglobin A1c all increased very substantially during integrated care. More than half of patients with baseline hypertension had this controlled within 90 days of beginning integrated care. Among patients hospitalized at any point during the study period, the probability of hospitalization in the first year of integrated care decreased by 18 percentage points, after controlling for other factors such as patient severity, insurance status, and demographics (p < .001). The average length of stay was also 32% shorter compared to the year prior to integrated care (p < .001). Savings due to reduced hospitalization frequency alone exceeded $1000 per patient. Data limitations restricted this study to a pre-/post-study design. However, the magnitude and consistency of findings across different outcomes suggest that for people with serious mental illness, integrated care can make a significant difference in rates of preventive care, health, and cost-related outcomes.

Supply factors as determinants of treatment costs: clinicians' assessments of a given set of referrals to community mental health centers in Norway.

BACKGROUND: Previous works that uses patterns of prior spending to predict future mental health care expenses (utilization models) are mainly concerned with demand (need) variables. In this paper, we introduce supply variables, both individual rater variables and center variables. The aim is to assess these variables' explanatory power, and to investigate whether not accounting for such variables could create biased estimates for the effects of need variables. METHODS: We employed an observational study design where the same set of referrals was assessed by a sample of clinicians, thus creating data with a panel structure being particularly relevant for analyzing supply factors. The referrals were obtained from Norwegian Community Mental Health Centers (outpatient services), and the clinicians assessed the referrals with respect to recommended treatment costs and health status. RESULTS: Supply variables accounted for more than 10% of the total variation and about one third of the explained variation. Two groups of supply variables, individual rater variables and center variables (institutions) were equally important. CONCLUSIONS: Our results confirm that supply factors are important but ignoring such variables, when analyzing demand variables, do not generally seem to produce biased (confounded) coefficients.

Understanding the Cost of a New Integrated Care Model to Serve CMHC Patients Who Have Serious Mental Illness.

People with serious mental illness, such as schizophrenia and bipolar disorder, experience premature mortality, often from cardiovascular disease (CVD). Unfortunately, people with serious mental illness typically are not screened or treated for CVD risk factors despite national guideline recommendations. Access to primary preventive care in community mental health settings has the potential to reduce early mortality rates in this population. The authors review best practices for developing an integrated care model for people with serious mental illness by considering economic feasibility and sustainability from the perspective of a community mental health clinic (CMHC). A process-mapping approach was used to gather information on clinic costs (staff roles, responsibilities, time, and salary) of serving 544 patients at one CMHC. The estimated annual cost of the model was measurable and modest, at $74 per person, suggesting that this model may be financially feasible.

The impact of the great recession on community-based mental health organizations: an analysis of top managers' perceptions of the economic downturn's effects and adaptive strategies used to manage the consequences in Ohio.

The Great Recession of 2007-2009 adversely affected the financial stability of the community-based mental health infrastructure in Ohio. This paper presents survey results of the type of adaptive strategies used by Ohio community-based mental health organizations to manage the consequences of the economic downturn. Results were aggregated into geographical classifications of rural, mid-sized urban, and urban. Across all groups, respondents perceived, to varying degrees, that the Great Recession posed a threat to their organization's survival. Urban organizations were more likely to implement adaptive strategies to expand operations while rural and midsized urban organizations implemented strategies to enhance internal efficiencies.

The impact of Assertive Community Treatment on utilization of primary care and other outpatient health services: the North Carolina experience.

BACKGROUND: A number of states have implemented Assertive Community Treatment (ACT) teams statewide. The extent to which team-based care in ACT programs substitutes or complements primary care and other types of health services is relatively unknown outside of clinical trials. OBJECTIVE: To analyze whether investments in ACT yield savings in primary care and other outpatient health services. DESIGN: Patterns of medical and mental health service use and costs were examined using Medicaid claims files from 2000 to 2002 in North Carolina. Two-part models and negative binomial models compared individuals on ACT (n = 1,065 distinct individuals) with two control groups of Medicaid enrollees with severe mental illness not receiving ACT services (n = 1,426 and n = 41,717 distinct individuals). RESULTS: We found no evidence that ACT affected utilization of other outpatient health services or primary care; however, ACT was associated with a decrease in other outpatient health expenditures (excluding ACT) through a reduction in the intensity with which these services were used. Consistent with prior literature, ACT also decreased the likelihood of emergency room visits and inpatient psychiatric stays. CONCLUSIONS: Given the increasing emphasis and efforts toward integrating physical health and behavioral health care, it is likely that ACT will continue to be challenged to meet the physical health needs of its consumers. To improve primary care receipt, this may mean a departure from traditional staffing patterns (e.g., the addition of a primary care doctor and nurse) and expansion of the direct services ACT provides to incorporate physical health treatments.

Innovation in health economic modelling of service improvements for longer-term depression: demonstration in a local health community.

BACKGROUND: The purpose of the analysis was to develop a health economic model to estimate the costs and health benefits of alternative National Health Service (NHS) service configurations for people with longer-term depression. METHOD: Modelling methods were used to develop a conceptual and health economic model of the current configuration of services in Sheffield, England for people with longer-term depression. Data and assumptions were synthesised to estimate cost per Quality Adjusted Life Years (QALYs). RESULTS: Three service changes were developed and resulted in increased QALYs at increased cost. Versus current care, the incremental cost-effectiveness ratio (ICER) for a self-referral service was £11,378 per QALY. The ICER was £2,227 per QALY for the dropout reduction service and £223 per QALY for an increase in non-therapy services. These results were robust when compared to current cost-effectiveness thresholds and accounting for uncertainty. CONCLUSIONS: Cost-effective service improvements for longer-term depression have been identified. Also identified were limitations of the current evidence for the long term impact of services.

Treatment of addicts in Bosnia and Herzegovina--constraints and opportunities.

Chronology of important historical events in Bosnia and Herzegovina during past two centuries indirectly influenced the incidence and prevalence of different psychoactive substances use and thus the organization of services for the treatment of persons who develop addiction symptoms. The organization of health system in the last war, 1992-1995, suffered enormous damage and the reform process which inevitably followed, included the area of mental health care services and the establishment of network of centers for mental health in the community (CMHC). The centers are functioning within the primary health care almost in whole country, with specialized centers for the prevention and treatment of addicts and the therapeutic communities, which today represents the basic organizational units to help people who have drug related issues. In this paper we will present the possibility of treatment of drug addicts in Bosnia and Herzegovina, from consulting services, psycho-education and early detection of disease, detoxification and substitution programs with Methadone and Suboxone, as well as programs of rehabilitation and resocialization. Although a very complicated political and administrative structure of the country, insufficient financial support, pronounced stigmatization of addicts, insufficient staffing and number of treatment centers are objective obstacles for progress in treatment of addicts, we believe that, with existing resources, these constraints can be converted into new opportunities in terms of improvement of treatment options in the future.